Provider Demographics
NPI:1720363617
Name:POTTS, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:POTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 W USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5267
Mailing Address - Country:US
Mailing Address - Phone:208-377-3581
Mailing Address - Fax:208-377-4165
Practice Address - Street 1:10580 W USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5267
Practice Address - Country:US
Practice Address - Phone:208-377-3581
Practice Address - Fax:208-377-4165
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist