Provider Demographics
NPI:1275868523
Name:WATSON, CORY PATRICK
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:PATRICK
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 1:5125 SKYWAY STE.F
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969
Mailing Address - Country:US
Mailing Address - Phone:530-876-2525
Mailing Address - Fax:530-876-2528
Practice Address - Street 1:5125 SKYWAY STE F
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5624
Practice Address - Country:US
Practice Address - Phone:530-876-2525
Practice Address - Fax:530-876-2528
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56519183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician