Provider Demographics
NPI:1508880899
Name:WATENPAUGH, MARK WESLEY JR (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WESLEY
Last Name:WATENPAUGH
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 702
Mailing Address - Street 2:236 WEST COLORADO AVE
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-0702
Mailing Address - Country:US
Mailing Address - Phone:970-728-3601
Mailing Address - Fax:970-728-1366
Practice Address - Street 1:236 WEST COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-0702
Practice Address - Country:US
Practice Address - Phone:970-728-3601
Practice Address - Fax:970-728-1366
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03840295Medicaid