Provider Demographics
NPI:1518985340
Name:WATSONVILLE PHARMACY INC
Entity Type:Organization
Organization Name:WATSONVILLE PHARMACY INC
Other - Org Name:WATSONVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:831-722-2141
Mailing Address - Street 1:1433 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-2742
Mailing Address - Country:US
Mailing Address - Phone:831-728-1818
Mailing Address - Fax:
Practice Address - Street 1:1433 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2742
Practice Address - Country:US
Practice Address - Phone:831-728-1818
Practice Address - Fax:831-728-8678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY482163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA482160Medicaid
2115035OtherPK
CAPHA482160Medicaid