MEDICARE: ERIC J POLCZYNSKI RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP0410102	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HSZ196	OTHER	NM	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982653036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC J POLCZYNSKI RPH

Provider Business Mailing Address
First Line	:	PO BOX 187
Second Line	:	12000 STONE LAKE ROAD
City	:	DULCE
State	:	NM
Zip	:	87528-0187
Country	:	US
Telephone Number	:	505-759-3291
Fax Number	:	505-759-7288

Provider Business Practice Location Address
First Line	:	JICARILLA SERVICE UNIT
Second Line	:	12000 STONE LAKE ROAD
City	:	DULCE
State	:	NM
Zip	:	87528-0187
Country	:	US
Telephone Number	:	505-759-3291
Fax Number	:	505-759-7288

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	05/27/2008

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