Provider Demographics
NPI:1124100664
Name:POTTER, KIM (RPH)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-3046
Mailing Address - Country:US
Mailing Address - Phone:770-227-2428
Mailing Address - Fax:770-227-3275
Practice Address - Street 1:131 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-3046
Practice Address - Country:US
Practice Address - Phone:770-227-2428
Practice Address - Fax:770-227-3275
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRPH018682OtherSTATE LIC.