Healthcare Provider Details

I. General information

NPI: 1578055026
Provider Name (Legal Business Name): PETER PONS BAUTISTA PHARMD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SHADOW LN PHARMACY
LAS VEGAS NV
89106-4194
US

IV. Provider business mailing address

620 SHADOW LN PHARMACY DEPARTMENT - PB
LAS VEGAS NV
89106-4194
US

V. Phone/Fax

Practice location:
  • Phone: 702-388-8479
  • Fax:
Mailing address:
  • Phone: 702-388-8479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number19662
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: