Healthcare Provider Details

I. General information

NPI: 1982653036
Provider Name (Legal Business Name): ERIC J POLCZYNSKI RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JICARILLA SERVICE UNIT 12000 STONE LAKE ROAD
DULCE NM
87528-0187
US

IV. Provider business mailing address

PO BOX 187 12000 STONE LAKE ROAD
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3291
  • Fax: 505-759-7288
Mailing address:
  • Phone: 505-759-3291
  • Fax: 505-759-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0410102
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: