Provider Demographics
NPI:1396396115
Name:PONNAMBALATH, JITH
Entity Type:Individual
Prefix:
First Name:JITH
Middle Name:
Last Name:PONNAMBALATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-1740
Mailing Address - Country:US
Mailing Address - Phone:410-225-2901
Mailing Address - Fax:
Practice Address - Street 1:2509 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1740
Practice Address - Country:US
Practice Address - Phone:410-225-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist