Provider Demographics
NPI:1508103276
Name:POLK, VICTORIA GRACE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:GRACE
Last Name:POLK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 OWL RDG
Mailing Address - Street 2:
Mailing Address - City:BRASSTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28902-6111
Mailing Address - Country:US
Mailing Address - Phone:727-222-9282
Mailing Address - Fax:
Practice Address - Street 1:320 OWL RDG
Practice Address - Street 2:
Practice Address - City:BRASSTOWN
Practice Address - State:NC
Practice Address - Zip Code:28902-6111
Practice Address - Country:US
Practice Address - Phone:727-222-9282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist