Provider Demographics
NPI:1669551123
Name:WATANABE, MICHAEL HEDE (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HEDE
Last Name:WATANABE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2181 MARSELINA
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782
Mailing Address - Country:US
Mailing Address - Phone:714-832-9790
Mailing Address - Fax:
Practice Address - Street 1:4201 W CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1505
Practice Address - Country:US
Practice Address - Phone:714-748-6333
Practice Address - Fax:714-748-6334
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH30243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist