Provider Demographics
NPI:1679004220
Name:POULTER, REBECCA (PHARMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:POULTER
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 1:1851 E BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-5911
Mailing Address - Country:US
Mailing Address - Phone:928-774-3294
Mailing Address - Fax:928-774-3297
Practice Address - Street 1:1851 E BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5911
Practice Address - Country:US
Practice Address - Phone:928-774-3294
Practice Address - Fax:928-774-3297
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS12904183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist