Healthcare Provider Details

I. General information

NPI: 1447591995
Provider Name (Legal Business Name): MR. SAM JACK POSTOLSKI070
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2013
Last Update Date: 03/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 S MAIN ST 2805 S MAIN ST
HIGH POINT NC
27263-1936
US

IV. Provider business mailing address

2805 S MAIN ST 2805 S MAIN ST
HIGH POINT NC
27263-1936
US

V. Phone/Fax

Practice location:
  • Phone: 336-431-1149
  • Fax: 336-431-8423
Mailing address:
  • Phone: 336-431-1149
  • Fax: 336-431-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23019
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: