Provider Demographics
NPI:1164770756
Name:WATERTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:WATERTOWN PHARMACY LLC
Other - Org Name:SPRING PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-955-2153
Mailing Address - Street 1:4689 SHORELINE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384
Mailing Address - Country:US
Mailing Address - Phone:952-471-3784
Mailing Address - Fax:952-471-1212
Practice Address - Street 1:4689 SHORELINE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384
Practice Address - Country:US
Practice Address - Phone:952-955-2153
Practice Address - Fax:952-471-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164770756Medicaid