Provider Demographics
NPI:1376823633
Name:WATT, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-5278
Mailing Address - Country:US
Mailing Address - Phone:614-638-1345
Mailing Address - Fax:
Practice Address - Street 1:250 E MIRACLE STRIP PKWY
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1924
Practice Address - Country:US
Practice Address - Phone:850-243-9557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist