Healthcare Provider Details

I. General information

NPI: 1144859638
Provider Name (Legal Business Name): PONCIANO F BAUTISTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 49TH AVE S
SEATTLE WA
98118-1228
US

IV. Provider business mailing address

4002 49TH AVE S
SEATTLE WA
98118-1228
US

V. Phone/Fax

Practice location:
  • Phone: 206-834-5647
  • Fax:
Mailing address:
  • Phone: 206-834-5647
  • Fax: 206-323-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00017744
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPH00017744
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00017744
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPH00017744
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberPH00017744
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH00017744
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberPH00017744
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH00017744
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: