Provider Demographics
NPI:1649320300
Name:RICHARD WATSON
Entity type:Organization
Organization Name:RICHARD WATSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:254-734-4040
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:GORMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76454-0249
Mailing Address - Country:US
Mailing Address - Phone:254-734-4040
Mailing Address - Fax:254-734-4041
Practice Address - Street 1:104 S. KENT ST.
Practice Address - Street 2:
Practice Address - City:GORMAN
Practice Address - State:TX
Practice Address - Zip Code:76454-0249
Practice Address - Country:US
Practice Address - Phone:254-734-4040
Practice Address - Fax:254-734-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1216340001Medicare ID - Type UnspecifiedMEDICARE PART B