Provider Demographics
NPI:1326799883
Name:WATT, CHANDLER BLAKE
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:BLAKE
Last Name:WATT
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 1:360 DINGENS ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14206-2319
Mailing Address - Country:US
Mailing Address - Phone:716-824-1721
Mailing Address - Fax:716-824-1227
Practice Address - Street 1:360 DINGENS ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14206-2319
Practice Address - Country:US
Practice Address - Phone:716-824-1721
Practice Address - Fax:716-824-1227
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30173307183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician