Healthcare Provider Details

I. General information

NPI: 1902429376
Provider Name (Legal Business Name): JACOB POTTS PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W MEDICAL PARK DR
LEXINGTON NC
27292-6773
US

IV. Provider business mailing address

1100 REVOLUTION MILL DR STE 10
GREENSBORO NC
27405-5067
US

V. Phone/Fax

Practice location:
  • Phone: 336-224-0931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29373
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number700355
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: