Provider Demographics
NPI:1538346804
Name:POLTORAK, KIM TERESE (RPH)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:TERESE
Last Name:POLTORAK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1728
Mailing Address - Country:US
Mailing Address - Phone:631-842-4658
Mailing Address - Fax:631-842-9493
Practice Address - Street 1:349 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2709
Practice Address - Country:US
Practice Address - Phone:631-842-4658
Practice Address - Fax:631-842-9493
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist