Provider Demographics
NPI:1104682053
Name:PONKRATOV, JESSICA PAVLOVNA (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:PAVLOVNA
Last Name:PONKRATOV
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 W RUTTER PKWY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-9220
Mailing Address - Country:US
Mailing Address - Phone:360-431-9047
Mailing Address - Fax:
Practice Address - Street 1:2929 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4811
Practice Address - Country:US
Practice Address - Phone:509-535-9056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61452112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist