Healthcare Provider Details

I. General information

NPI: 1164199162
Provider Name (Legal Business Name): CLAIRE POTTEBAUM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

2300 DIAMOND MESA TRL SW APT 9004
ALBUQUERQUE NM
87121-3717
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24161
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: