Provider Demographics
NPI:1972601904
Name:THE WATTS CO OF MARIANNA INC
Entity Type:Organization
Organization Name:THE WATTS CO OF MARIANNA INC
Other - Org Name:WACO DRUGS AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-482-5781
Mailing Address - Street 1:4154 LAFAYETTE ST STE G
Mailing Address - Street 2:ST G
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-5655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4154 LAFAYETTE ST STE G
Practice Address - Street 2:ST G
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-5655
Practice Address - Country:US
Practice Address - Phone:850-482-5781
Practice Address - Fax:850-482-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH3054333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1014391OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL101755100Medicaid