Provider Demographics
NPI:1639595051
Name:POTOCKI, EDMUND
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:POTOCKI
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 1:2 PINE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-5240
Mailing Address - Country:US
Mailing Address - Phone:973-756-1005
Mailing Address - Fax:
Practice Address - Street 1:123 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:MATSHALLS CREEK
Practice Address - State:PA
Practice Address - Zip Code:18335
Practice Address - Country:US
Practice Address - Phone:570-223-2600
Practice Address - Fax:570-223-2600
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01476400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist