Provider Demographics
NPI:1407867062
Name:WATERS PHARMACY INC
Entity Type:Organization
Organization Name:WATERS PHARMACY INC
Other - Org Name:BRISTOW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-392-4020
Mailing Address - Street 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:45167-1232
Mailing Address - Country:US
Mailing Address - Phone:937-392-4020
Mailing Address - Fax:937-392-4078
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:OH
Practice Address - Zip Code:45167-1232
Practice Address - Country:US
Practice Address - Phone:937-392-4020
Practice Address - Fax:937-392-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0209760003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0460255Medicaid
2073985OtherPK
OH0460255Medicaid