Provider Demographics
NPI:1033489927
Name:WATSON, LARRY VINCENT
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:VINCENT
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 WINNETKA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4925
Mailing Address - Country:US
Mailing Address - Phone:763-545-6466
Mailing Address - Fax:763-545-8001
Practice Address - Street 1:4200 WINNETKA AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4925
Practice Address - Country:US
Practice Address - Phone:763-545-6466
Practice Address - Fax:763-545-8001
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist