MEDICARE: DR. JOSHUA RYAN POTRZEBA PHARM.D., BCGP

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	1835G0303X	Geriatric Pharmacist	10628594-1701	UT
2	183500000X	Pharmacist	0202210735	VA

General Provider Information

NPI Number	:	1568746527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSHUA RYAN POTRZEBA PHARM.D., BCGP

Provider Business Mailing Address
First Line	:	2525 S LAKE PARK BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-8230
Country	:	US
Telephone Number	:	801-982-4733
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 S LAKE PARK BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-8230
Country	:	US
Telephone Number	:	801-982-4733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2011
Last Update Date	:	12/03/2018

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