Provider Demographics
NPI:1710202098
Name:POLASEK, DAVID RONALD (RPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RONALD
Last Name:POLASEK
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 1:114 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-0270
Mailing Address - Country:US
Mailing Address - Phone:361-275-3332
Mailing Address - Fax:361-275-3829
Practice Address - Street 1:515 N ESPLANADE
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-0270
Practice Address - Country:US
Practice Address - Phone:361-275-3332
Practice Address - Fax:361-275-3829
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143644Medicaid