Provider Demographics
NPI:1275815797
Name:PONTIOUS, DAVID L (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:PONTIOUS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 M 37 S
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-8508
Mailing Address - Country:US
Mailing Address - Phone:231-943-3147
Mailing Address - Fax:
Practice Address - Street 1:1029 M 37 S
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-8508
Practice Address - Country:US
Practice Address - Phone:231-943-3147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2011-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039037183500000X
MO040865183500000X
KS1-10442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist