Provider Demographics
NPI:1538686027
Name:WATSON, ANDRE J
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:J
Last Name:WATSON
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 1:1287 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-5018
Mailing Address - Country:US
Mailing Address - Phone:304-264-9004
Mailing Address - Fax:
Practice Address - Street 1:1287 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-5018
Practice Address - Country:US
Practice Address - Phone:304-264-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24786183500000X
VA0202215705183500000X
WVRP0009957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist