Provider Demographics
NPI:1326411976
Name:POLAK, PETER (PHARMD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:POLAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 HIGHWAY 3
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-5163
Mailing Address - Country:US
Mailing Address - Phone:281-337-3595
Mailing Address - Fax:281-337-4759
Practice Address - Street 1:4016 HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-5163
Practice Address - Country:US
Practice Address - Phone:281-337-3595
Practice Address - Fax:281-337-4759
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist