Provider Demographics
NPI:1326619438
Name:WATSON, BRANDON TYLER
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:TYLER
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 1:8604 HIGHLANDS TRCE
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-3819
Mailing Address - Country:US
Mailing Address - Phone:205-612-5450
Mailing Address - Fax:
Practice Address - Street 1:2200 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MOODY
Practice Address - State:AL
Practice Address - Zip Code:35004-3241
Practice Address - Country:US
Practice Address - Phone:205-640-3237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist