Provider Demographics
NPI:1134749948
Name:PONEWASH, ANTONIETTE
Entity type:Individual
Prefix:
First Name:ANTONIETTE
Middle Name:
Last Name:PONEWASH
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 1:525 N GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3482
Mailing Address - Country:US
Mailing Address - Phone:972-289-1300
Mailing Address - Fax:972-289-9308
Practice Address - Street 1:525 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3482
Practice Address - Country:US
Practice Address - Phone:972-289-1300
Practice Address - Fax:972-289-9308
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX378211835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist