Provider Demographics
NPI:1578219416
Name:POLYNESIA INC
Entity Type:Organization
Organization Name:POLYNESIA INC
Other - Org Name:CLINT MOORE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSHUVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-245-6985
Mailing Address - Street 1:1906 CLINT MOORE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2663
Mailing Address - Country:US
Mailing Address - Phone:561-245-6985
Mailing Address - Fax:
Practice Address - Street 1:1906 CLINT MOORE RD STE 4
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2663
Practice Address - Country:US
Practice Address - Phone:561-245-6985
Practice Address - Fax:561-237-8045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy