Provider Demographics
NPI:1790085108
Name:POTTER, DOUGLAS KENJI (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:KENJI
Last Name:POTTER
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 1:1632 HOVER ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2441
Mailing Address - Country:US
Mailing Address - Phone:303-776-0508
Mailing Address - Fax:303-684-8468
Practice Address - Street 1:1632 HOVER ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2441
Practice Address - Country:US
Practice Address - Phone:303-776-0508
Practice Address - Fax:303-684-8468
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist