Healthcare Provider Details

I. General information

NPI: 1700876422
Provider Name (Legal Business Name): BYRD WATSON DRUG CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 W BROADWAY
CENTRALIA IL
62801-5309
US

IV. Provider business mailing address

1071 W BROADWAY
CENTRALIA IL
62801-5309
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-2200
  • Fax: 618-533-0566
Mailing address:
  • Phone: 618-532-2200
  • Fax: 618-533-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. WESLEY N BREEZE
Title or Position: OWNER PRES
Credential: RPH
Phone: 618-532-2200