Healthcare Provider Details

I. General information

NPI: 1073594859
Provider Name (Legal Business Name): POTTER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S 6TH ST
PETERSBURG IL
62675-1553
US

IV. Provider business mailing address

PO BOX 498
PETERSBURG IL
62675-0498
US

V. Phone/Fax

Practice location:
  • Phone: 217-632-2287
  • Fax: 217-632-2033
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054006072
License Number StateIL

VIII. Authorized Official

Name: PATRICK POTTER
Title or Position: PRESIDENT
Credential:
Phone: 217-632-2288