Provider Demographics
NPI:1578055026
Name:BAUTISTA, PETER PONS (PHARMD, MBA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:PONS
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SHADOW LN
Mailing Address - Street 2:PHARMACY DEPARTMENT - PB
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4194
Mailing Address - Country:US
Mailing Address - Phone:702-388-8479
Mailing Address - Fax:
Practice Address - Street 1:620 SHADOW LN
Practice Address - Street 2:PHARMACY
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4194
Practice Address - Country:US
Practice Address - Phone:702-388-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV196623336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy