Provider Demographics
NPI:1164135224
Name:POLUS, MASSARA K (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MASSARA
Middle Name:K
Last Name:POLUS
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11858 W ALBANY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2479
Mailing Address - Country:US
Mailing Address - Phone:619-456-7173
Mailing Address - Fax:
Practice Address - Street 1:999 N CURTIS RD STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1331
Practice Address - Country:US
Practice Address - Phone:208-367-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP10431OtherBOARD OF PHARMACY