Provider Demographics
NPI:1144859638
Name:BAUTISTA, PONCIANO F
Entity type:Individual
Prefix:
First Name:PONCIANO
Middle Name:F
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 49TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1228
Mailing Address - Country:US
Mailing Address - Phone:206-834-5647
Mailing Address - Fax:206-323-9206
Practice Address - Street 1:4002 49TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1228
Practice Address - Country:US
Practice Address - Phone:206-834-5647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000177443336C0002X, 3336C0003X, 3336C0004X, 3336H0001X, 3336I0012X, 3336L0003X, 3336M0002X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy