Provider Demographics
NPI:1316543309
Name:PONTIOUS, BROCK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:
Last Name:PONTIOUS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 MISSISSIPPI AVE UNIT E
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2472
Mailing Address - Country:US
Mailing Address - Phone:314-402-2466
Mailing Address - Fax:
Practice Address - Street 1:9141 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3722
Practice Address - Country:US
Practice Address - Phone:314-432-2296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019003509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1189214OtherCVS HEALTH