Provider Demographics
NPI:1407459878
Name:POTENZONE, DOMENIC (RPH)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:
Last Name:POTENZONE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-3305
Mailing Address - Country:US
Mailing Address - Phone:781-596-3277
Mailing Address - Fax:781-596-8378
Practice Address - Street 1:35 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-3305
Practice Address - Country:US
Practice Address - Phone:781-596-3277
Practice Address - Fax:781-596-8378
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist