Healthcare Provider Details

I. General information

NPI: 1467550970
Provider Name (Legal Business Name): MR. ANDREW M POLAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/09/2020
Certification Date: 05/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 COMMERCE RD
VESTAL NY
13850-2242
US

IV. Provider business mailing address

3252 HUNTERS LANDING RD
BINGHAMTON NY
13903-5614
US

V. Phone/Fax

Practice location:
  • Phone: 888-319-1818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number035821
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: