Provider Demographics
NPI:1609630151
Name:POTTS, MILES
Entity Type:Individual
Prefix:
First Name:MILES
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 1:9012 S INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6638
Mailing Address - Country:US
Mailing Address - Phone:773-954-4918
Mailing Address - Fax:
Practice Address - Street 1:655 ELM PL
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3132
Practice Address - Country:US
Practice Address - Phone:847-266-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist