MEDICARE: POTTER PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	054006072	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2023312	OTHER		PK

General Provider Information

NPI Number	:	1073594859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTTER PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 498
Second Line	:
City	:	PETERSBURG
State	:	IL
Zip	:	62675-0498
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S 6TH ST
Second Line	:
City	:	PETERSBURG
State	:	IL
Zip	:	62675-1553
Country	:	US
Telephone Number	:	217-632-2287
Fax Number	:	217-632-2033

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICK POTTER
Credential	:
Telephone Number	:	217-632-2288

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	03/06/2014

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Directions to “POTTER PHARMACY INC ” Practice Location

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