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NPI Code Detail

MEDICARE: LARRY VINCENT WATSON

MEDICARE: LARRY VINCENT WATSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist116415MN

General Provider Information

NPI Number : 1033489927
Entity Type Code : Individual
Provider Name (Legal Business Name) : LARRY VINCENT WATSON
Provider Business Mailing Address
First Line : 4200 WINNETKA AVE N
Second Line :
City : NEW HOPE
State : MN
Zip : 55428-4925
Country : US
Telephone Number : 763-545-6466
Fax Number : 763-545-8001
Provider Business Practice Location Address
First Line : 4200 WINNETKA AVE N
Second Line :
City : NEW HOPE
State : MN
Zip : 55428-4925
Country : US
Telephone Number : 763-545-6466
Fax Number : 763-545-8001
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/09/2012
Last Update Date : 01/09/2012

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