Provider Demographics
NPI:1194320846
Name:PONDS, MARK ANTOINE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTOINE
Last Name:PONDS
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 1:2365 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3167
Mailing Address - Country:US
Mailing Address - Phone:301-932-8260
Mailing Address - Fax:
Practice Address - Street 1:2365 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3167
Practice Address - Country:US
Practice Address - Phone:301-932-8260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist