Provider Demographics
NPI:1700876422
Name:BYRD WATSON DRUG CO
Entity Type:Organization
Organization Name:BYRD WATSON DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-532-2200
Mailing Address - Street 1:1071 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5309
Mailing Address - Country:US
Mailing Address - Phone:618-532-2200
Mailing Address - Fax:618-533-0566
Practice Address - Street 1:1071 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5309
Practice Address - Country:US
Practice Address - Phone:618-532-2200
Practice Address - Fax:618-533-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1436977OtherNCPDP
IL=========002Medicaid
IL=========002Medicaid