Healthcare Provider Details

I. General information

NPI: 1720363617
Provider Name (Legal Business Name): VICKI POTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10580 W USTICK RD
BOISE ID
83704-5267
US

IV. Provider business mailing address

10580 W USTICK RD
BOISE ID
83704-5267
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-3581
  • Fax: 208-377-4165
Mailing address:
  • Phone: 208-377-3581
  • Fax: 208-377-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP3870
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: