Provider Demographics
NPI:1639478845
Name:POLUCHA, JAMES (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:POLUCHA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2187 FOURTH STREET
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-429-5356
Mailing Address - Fax:651-429-0425
Practice Address - Street 1:2187 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-429-5356
Practice Address - Fax:651-429-0425
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist