Provider Demographics
NPI:1265712707
Name:POTTS, KEVIN L (RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
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 1:1345B LAKE MURRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2839
Mailing Address - Country:US
Mailing Address - Phone:803-749-5924
Mailing Address - Fax:803-749-3763
Practice Address - Street 1:1345B LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2839
Practice Address - Country:US
Practice Address - Phone:803-749-5924
Practice Address - Fax:803-749-3763
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist