Healthcare Provider Details

I. General information

NPI: 1194476598
Provider Name (Legal Business Name): POLKA HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 WHITE RIDGE PLACE 17
THOUSAND OAKS CA
91362-9136
US

IV. Provider business mailing address

PO BOX 1316
THOUSAND OAKS CA
91358-0316
US

V. Phone/Fax

Practice location:
  • Phone: 747-287-9012
  • Fax:
Mailing address:
  • Phone: 747-287-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HYUNG MIN LEE
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 747-287-9012