Provider Demographics
NPI:1790814614
Name:PONCE DE LEON, IVONNE (PH)
Entity Type:Individual
Prefix:MRS
First Name:IVONNE
Middle Name:
Last Name:PONCE DE LEON
Suffix:
Gender:F
Credentials:PH
Other - Prefix:MRS
Other - First Name:IVONNE
Other - Middle Name:
Other - Last Name:PONCE DE LEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PH
Mailing Address - Street 1:25 DE JULIO
Mailing Address - Street 2:CENTRO COMERCIAL LA QUINTA
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698
Mailing Address - Country:US
Mailing Address - Phone:787-835-2173
Mailing Address - Fax:787-856-1922
Practice Address - Street 1:25 DE JULIO
Practice Address - Street 2:CENTRO COMERCIAL LA QUINTA
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698
Practice Address - Country:US
Practice Address - Phone:787-835-2173
Practice Address - Fax:787-856-1922
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist