Provider Demographics
NPI:1386050359
Name:POTTENGER, CHARLES (PHARMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:POTTENGER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 THAIN RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5530
Mailing Address - Country:US
Mailing Address - Phone:208-743-5515
Mailing Address - Fax:
Practice Address - Street 1:523 THAIN RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5530
Practice Address - Country:US
Practice Address - Phone:208-743-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist