Provider Demographics
NPI:1093046112
Name:POTUCEK, MARY ELLEN (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:POTUCEK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 BELL BLVD
Mailing Address - Street 2:APT 9C
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2024
Mailing Address - Country:US
Mailing Address - Phone:718-229-1408
Mailing Address - Fax:
Practice Address - Street 1:310 E 14TH ST
Practice Address - Street 2:PHARMACY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4201
Practice Address - Country:US
Practice Address - Phone:212-979-4379
Practice Address - Fax:212-353-5915
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist