Provider Demographics
NPI:1821195462
Name:POULSON, WARREN B (RPH)
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:B
Last Name:POULSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18 DUCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-1115
Mailing Address - Country:US
Mailing Address - Phone:631-728-9275
Mailing Address - Fax:631-723-0950
Practice Address - Street 1:58 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-2326
Practice Address - Country:US
Practice Address - Phone:631-288-4345
Practice Address - Fax:631-288-4363
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01645401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01645401OtherPHARMACY LISCENSE