Healthcare Provider Details

I. General information

NPI: 1508880899
Provider Name (Legal Business Name): MARK WESLEY WATENPAUGH JR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 WEST COLORADO AVE
TELLURIDE CO
81435-0702
US

IV. Provider business mailing address

PO BOX 702 236 WEST COLORADO AVE
TELLURIDE CO
81435-0702
US

V. Phone/Fax

Practice location:
  • Phone: 970-728-3601
  • Fax: 970-728-1366
Mailing address:
  • Phone: 970-728-3601
  • Fax: 970-728-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9580
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: