Provider Demographics
NPI:1043997182
Name:BYRD-WATSON TIMES SQUARE DRUG CO
Entity Type:Organization
Organization Name:BYRD-WATSON TIMES SQUARE DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER OF THE CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-244-5400
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0024
Mailing Address - Country:US
Mailing Address - Phone:618-244-5400
Mailing Address - Fax:618-244-5409
Practice Address - Street 1:3401 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2201
Practice Address - Country:US
Practice Address - Phone:618-244-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy