Provider Demographics
NPI:1033518659
Name:POTTHOFF, MARIE LYNN
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LYNN
Last Name:POTTHOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1747
Mailing Address - Country:US
Mailing Address - Phone:605-343-2248
Mailing Address - Fax:605-342-9258
Practice Address - Street 1:1111 E NORTH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1747
Practice Address - Country:US
Practice Address - Phone:605-343-2248
Practice Address - Fax:605-342-9258
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist