Provider Demographics
NPI:1033827902
Name:POTTER, CLAYTON
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E ROOSEVELT ST APT 3090
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4308
Mailing Address - Country:US
Mailing Address - Phone:307-258-8261
Mailing Address - Fax:
Practice Address - Street 1:4323 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2250
Practice Address - Country:US
Practice Address - Phone:602-404-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS026183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist