Provider Demographics
NPI:1679800965
Name:POTTER, JENNIFER PAIGE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:PAIGE
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 1:3301 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7959
Mailing Address - Country:US
Mailing Address - Phone:903-663-4362
Mailing Address - Fax:903-663-4627
Practice Address - Street 1:3301 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7959
Practice Address - Country:US
Practice Address - Phone:903-663-4362
Practice Address - Fax:903-663-4627
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist