Provider Demographics
NPI:1548800378
Name:POTTER, MATTHEW H
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:H
Last Name:POTTER
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 1:3746 ALABAMA ST APT 203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5917
Mailing Address - Country:US
Mailing Address - Phone:740-803-1887
Mailing Address - Fax:
Practice Address - Street 1:7100 BROADWAY
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1401
Practice Address - Country:US
Practice Address - Phone:619-697-3415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist