Provider Demographics
NPI:1215532429
Name:POLACEK, MINDY
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:POLACEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-0216
Mailing Address - Country:US
Mailing Address - Phone:712-352-4152
Mailing Address - Fax:
Practice Address - Street 1:545 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0216
Practice Address - Country:US
Practice Address - Phone:712-352-4152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA223793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy