Provider Demographics
NPI:1922608090
Name:WATSON, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WATSON
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 1:340 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1621
Mailing Address - Country:US
Mailing Address - Phone:708-655-7001
Mailing Address - Fax:
Practice Address - Street 1:137 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2316
Practice Address - Country:US
Practice Address - Phone:708-409-0046
Practice Address - Fax:708-409-0268
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist