Provider Demographics
NPI:1407485915
Name:POTTS, STEPHEN DEAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DEAN
Last Name:POTTS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2312
Mailing Address - Country:US
Mailing Address - Phone:618-919-4009
Mailing Address - Fax:618-516-8988
Practice Address - Street 1:709 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2312
Practice Address - Country:US
Practice Address - Phone:618-919-4009
Practice Address - Fax:618-516-8988
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL810998287001Medicaid