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General NPI Number Information
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NPI Number | 1326239054
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Entity Type | Organization
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Legal Business Name | GULF BEND MH-MR CENTER
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Dates
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Enumeration Date | 08/07/2007
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Last Update Date | 11/21/2008
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Provider Practice Location Address
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Address Line | 6502 NURSERY DRIVE SUITE 100
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City | VICTORIA
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State | TX
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Zip | 77904-1178
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Country | US
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Telephone | 361-575-0611
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Fax | 361-578-5500
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Provider Business Mailing Address
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Address Line | 6502 NURSERY DRIVE SUITE 100
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City | VICTORIA
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State | TX
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Zip | 77904-1178
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Country | US
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Telephone | 361-575-0611
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Fax | 361-578-5500
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DONALD L. POLZIN
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Credential |
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Telephone | 361-582-2314
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 13921
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License Number State | TX
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