Healthcare Provider Details

I. General information

NPI: 1720013279
Provider Name (Legal Business Name): WATERTOWN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 LEWIS AVE S SUITE 101
WATERTOWN MN
55388-4500
US

IV. Provider business mailing address

204 LEWIS AVE S SUITE 101
WATERTOWN MN
55388-4500
US

V. Phone/Fax

Practice location:
  • Phone: 952-955-2153
  • Fax:
Mailing address:
  • Phone: 952-955-2153
  • Fax: 952-955-3067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number261954
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number261954
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number261954
License Number StateMN

VIII. Authorized Official

Name: ROSEMARY LOUISE ROSDAHL
Title or Position: CHIEF MANAGER
Credential: RPH
Phone: 952-955-2153