Provider Demographics
NPI:1902203185
Name:POTNIS, DAKSHA
Entity Type:Individual
Prefix:
First Name:DAKSHA
Middle Name:
Last Name:POTNIS
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 1:1801 GIBSON BLVD SE
Mailing Address - Street 2:APT 2071
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3348
Mailing Address - Country:US
Mailing Address - Phone:913-484-5123
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:APT 2071
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:913-484-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-16442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist