Provider Demographics
NPI:1689950644
Name:POTTS, GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7675 W KANGAROO LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BAILEYS HARBOR
Mailing Address - State:WI
Mailing Address - Zip Code:54202-9138
Mailing Address - Country:US
Mailing Address - Phone:920-839-9359
Mailing Address - Fax:
Practice Address - Street 1:808 S DULUTH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3807
Practice Address - Country:US
Practice Address - Phone:920-746-5245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8511-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist