Healthcare Provider Details

I. General information

NPI: 1740890433
Provider Name (Legal Business Name): POLARIS JACK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3072 DICK POND RD UNIT 2
MYRTLE BEACH SC
29588-6954
US

IV. Provider business mailing address

3072 DICK POND RD UNIT 2
MYRTLE BEACH SC
29588-6954
US

V. Phone/Fax

Practice location:
  • Phone: 843-293-7979
  • Fax: 843-293-6499
Mailing address:
  • Phone: 843-293-7979
  • Fax: 843-293-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. FORREST WESTLEY
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 843-293-7979