Healthcare Provider Details

I. General information

NPI: 1518959683
Provider Name (Legal Business Name): SUSAN L PONCE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CRESCENT AVE
AVALON CA
90704
US

IV. Provider business mailing address

PO BOX 851
AVALON CA
90704-0851
US

V. Phone/Fax

Practice location:
  • Phone: 310-510-0189
  • Fax: 310-510-2585
Mailing address:
  • Phone: 310-510-0189
  • Fax: 310-510-2585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number39705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: