Provider Demographics
NPI:1215530035
Name:POLASEK, ROBERT JOHN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:POLASEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 INDIAN LDG
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-4409
Mailing Address - Country:US
Mailing Address - Phone:210-464-8240
Mailing Address - Fax:
Practice Address - Street 1:2100 SE LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78220-4927
Practice Address - Country:US
Practice Address - Phone:210-548-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist