Healthcare Provider Details

I. General information

NPI: 1912139668
Provider Name (Legal Business Name): JESSICA MARIE POTHAST PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W CASABLANCA AVE
CANNON AFB NM
88103-5009
US

IV. Provider business mailing address

208 W CASABLANCA AVE
CANNON AFB NM
88103-5009
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-4028
  • Fax:
Mailing address:
  • Phone: 575-784-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03129369
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: