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General NPI Number Information
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NPI Number | 1881061984
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Entity Type | Individual
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Provider Name | PETER PONOMAREV
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Gender | Male
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 08/25/2015
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Provider Practice Location Address
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Address Line | 15600 W 10 MILE RD UNIT 1B
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2148
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Country | US
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Telephone | 248-569-7578
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Fax |
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Provider Business Mailing Address
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Address Line | 2516 BLACK PINE TRAIL DR
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City | TROY
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State | MI
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Zip | 48098-4102
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5302032680
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License Number State | MI
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