Provider Demographics
NPI:1073150819
Name:WATSON, SAMANTHA NICHOLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:NICHOLE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8787 BONO RD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-8017
Mailing Address - Country:US
Mailing Address - Phone:217-508-3884
Mailing Address - Fax:
Practice Address - Street 1:4714 S US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4413
Practice Address - Country:US
Practice Address - Phone:812-232-8379
Practice Address - Fax:812-232-8472
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.300996183500000X
IN26027157A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist