Provider Demographics
NPI:1629733076
Name:PONTO, MICHELLE K
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:PONTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25752 BURROUGHS PL
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1126
Mailing Address - Country:US
Mailing Address - Phone:661-755-4357
Mailing Address - Fax:
Practice Address - Street 1:26861 SIERRA HWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2274
Practice Address - Country:US
Practice Address - Phone:661-251-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty