Provider Demographics
NPI:1114969730
Name:WATERMONT PHARMACY
Entity Type:Organization
Organization Name:WATERMONT PHARMACY
Other - Org Name:WATERMONT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:LARE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-465-0552
Mailing Address - Street 1:4900 WATERLOO RD # A
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6664
Mailing Address - Country:US
Mailing Address - Phone:410-465-0552
Mailing Address - Fax:410-465-0553
Practice Address - Street 1:4900 WATERLOO RD # A
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6664
Practice Address - Country:US
Practice Address - Phone:410-465-0552
Practice Address - Fax:410-465-0553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP008203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2103896OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD011682300Medicaid