MEDICARE: RANDAL LYNN WATT PHARMD

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
1	183500000X	Pharmacist	6805	NM

General Provider Information

NPI Number	:	1861772717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDAL LYNN WATT PHARMD

Provider Business Mailing Address
First Line	:	710 PASEO DEL PUEBLO SUR STE A
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-5998
Country	:	US
Telephone Number	:	575-758-1203
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 PASEO DEL PUEBLO SUR STE A
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-5998
Country	:	US
Telephone Number	:	575-758-1203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2011
Last Update Date	:	08/24/2011

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