Provider Demographics
NPI:1740890433
Name:POLARIS JACK, INC.
Entity type:Organization
Organization Name:POLARIS JACK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:843-293-7979
Mailing Address - Street 1:3072 DICK POND RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6954
Mailing Address - Country:US
Mailing Address - Phone:843-293-7979
Mailing Address - Fax:843-293-6499
Practice Address - Street 1:3072 DICK POND RD UNIT 2
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6954
Practice Address - Country:US
Practice Address - Phone:843-293-7979
Practice Address - Fax:843-293-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy