Provider Demographics
NPI:1922249127
Name:POTTERS HOUSE APOTHECARY INC
Entity Type:Organization
Organization Name:POTTERS HOUSE APOTHECARY INC
Other - Org Name:POTTER'S HOUSE APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:623-362-9322
Mailing Address - Street 1:21585 N 77TH AVE
Mailing Address - Street 2:STE 1500
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382
Mailing Address - Country:US
Mailing Address - Phone:623-362-9322
Mailing Address - Fax:623-362-9001
Practice Address - Street 1:21585 N 77TH AVE
Practice Address - Street 2:STE 1500
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382
Practice Address - Country:US
Practice Address - Phone:623-362-9322
Practice Address - Fax:623-362-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
AZY0050433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119474OtherPK
AZ432524Medicaid