Provider Demographics
NPI:1336791458
Name:WATSON, KACIE MARIE
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:MARIE
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 1:39701 APPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-0266
Mailing Address - Country:US
Mailing Address - Phone:225-439-0962
Mailing Address - Fax:
Practice Address - Street 1:100 WOMANS WAY STE SSB1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5100
Practice Address - Country:US
Practice Address - Phone:225-924-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist