Provider Demographics
NPI:1275855363
Name:WATTA, BRIAN L (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:L
Last Name:WATTA
Suffix:
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 1:1543 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-3620
Mailing Address - Country:US
Mailing Address - Phone:516-396-8842
Mailing Address - Fax:
Practice Address - Street 1:45 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4100
Practice Address - Country:US
Practice Address - Phone:516-396-8842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist