Provider Demographics
NPI:1073850442
Name:POLL, JACK A (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:POLL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 SUGARBUSH CT SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9798
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2245 84TH ST SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8666
Practice Address - Country:US
Practice Address - Phone:616-878-6047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-05
Last Update Date:2013-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist