Provider Demographics
NPI:1154453447
Name:PONDER, MICHAEL STANLEY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STANLEY
Last Name:PONDER
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 1:4306 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-2542
Mailing Address - Country:US
Mailing Address - Phone:510-536-2977
Mailing Address - Fax:510-533-5210
Practice Address - Street 1:7200 BANCROFT AVE
Practice Address - Street 2:SUITE #268
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2403
Practice Address - Country:US
Practice Address - Phone:510-638-7323
Practice Address - Fax:510-430-2860
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH38499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH38499OtherSTATE PHARMACY LICENSE