Provider Demographics
NPI:1417419417
Name:POLA, HERVE WAFO
Entity Type:Individual
Prefix:
First Name:HERVE
Middle Name:WAFO
Last Name:POLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 GEORGETOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-5427
Mailing Address - Country:US
Mailing Address - Phone:517-316-6644
Mailing Address - Fax:
Practice Address - Street 1:1705 W MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2660
Practice Address - Country:US
Practice Address - Phone:517-672-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351013135183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician