Provider Demographics
NPI:1568943587
Name:POTTER, BREANNA LAINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LAINE
Last Name:POTTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 BEGLIS PKWY
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5606
Mailing Address - Country:US
Mailing Address - Phone:337-625-2660
Mailing Address - Fax:
Practice Address - Street 1:1508 BEGLIS PKWY
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5606
Practice Address - Country:US
Practice Address - Phone:337-625-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.22481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist