Provider Demographics
NPI:1356688154
Name:POTTS, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:POTTS
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 1:8330 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5137
Mailing Address - Country:US
Mailing Address - Phone:941-907-2844
Mailing Address - Fax:941-907-2825
Practice Address - Street 1:8330 MARKET ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-5137
Practice Address - Country:US
Practice Address - Phone:941-907-2844
Practice Address - Fax:941-907-2925
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0026567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist