Provider Demographics
NPI:1396794954
Name:POTTS, EDWIN RAY (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:RAY
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 1:1116 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2324
Mailing Address - Country:US
Mailing Address - Phone:618-842-6007
Mailing Address - Fax:618-842-4816
Practice Address - Street 1:1116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2324
Practice Address - Country:US
Practice Address - Phone:618-842-6007
Practice Address - Fax:618-842-4816
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371200692001Medicaid
IL0009632011OtherBLUE CROSS BLUE SHIELD
IL1453531OtherNABP
IL1453531OtherNABP