Provider Demographics
NPI:1982653036
Name:POLCZYNSKI, ERIC J (RPH)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:POLCZYNSKI
Suffix:
Gender:M
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:PO BOX 187
Mailing Address - Street 2:12000 STONE LAKE ROAD
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:505-759-3291
Mailing Address - Fax:505-759-7288
Practice Address - Street 1:JICARILLA SERVICE UNIT
Practice Address - Street 2:12000 STONE LAKE ROAD
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:505-759-7288
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP0410102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NM320057Medicare Oscar/Certification