Healthcare Provider Details

I. General information

NPI: 1740508712
Provider Name (Legal Business Name): KOH M WATANABE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24829 DEL PRADO
DANA POINT CA
92629-2852
US

IV. Provider business mailing address

24829 DEL PRADO
DANA POINT CA
92629-2852
US

V. Phone/Fax

Practice location:
  • Phone: 949-493-5100
  • Fax: 949-493-7631
Mailing address:
  • Phone: 949-493-5100
  • Fax: 949-493-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number43536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: