1285937946 NPI number — DR. DEREK MICHAEL POLLY PHARMD

Table of content: DR. DEREK MICHAEL POLLY PHARMD (NPI 1285937946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285937946 NPI number — DR. DEREK MICHAEL POLLY PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLY
Provider First Name:
DEREK
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285937946
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1364 CLIFTON RD NE
Provider Second Line Business Mailing Address:
PHARMACY DEPARTMENT
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30322-1059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-712-7150
Provider Business Mailing Address Fax Number:
404-712-7577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1364 CLIFTON RD NE
Provider Second Line Business Practice Location Address:
PHARMACY DEPARTMENT
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30322-1059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-712-7150
Provider Business Practice Location Address Fax Number:
404-712-7577
Provider Enumeration Date:
12/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P0018X , with the licence number:  RPH024861 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com