Provider Demographics
NPI:1770685083
Name:POLK, MARY CAROLE M (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY CAROLE
Middle Name:M
Last Name:POLK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:AR
Mailing Address - Zip Code:72029
Mailing Address - Country:US
Mailing Address - Phone:870-747-3304
Mailing Address - Fax:
Practice Address - Street 1:333 MADISON STREET
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:AR
Practice Address - Zip Code:72029
Practice Address - Country:US
Practice Address - Phone:870-747-3304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR281107-48-001OtherSALES AND USE TAX NUMBER
LA1291951Medicaid