Provider Demographics
NPI:1356017891
Name:POTILLOR, REENA
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:POTILLOR
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 1:2751 DEL PASO RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-2303
Mailing Address - Country:US
Mailing Address - Phone:916-285-9372
Mailing Address - Fax:
Practice Address - Street 1:2751 DEL PASO RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95835-2303
Practice Address - Country:US
Practice Address - Phone:916-285-9372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67924183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548276835Medicaid