Provider Demographics
NPI:1356625313
Name:PONEN, IAN R (PHARMD)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:R
Last Name:PONEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21903-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5319 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MD
Practice Address - Zip Code:21903-2606
Practice Address - Country:US
Practice Address - Phone:410-642-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist