Healthcare Provider Details

I. General information

NPI: 1881670388
Provider Name (Legal Business Name): WATTERS BROS DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 CRAWFORD AVE
NORTHERN CAMBRIA PA
15714-1341
US

IV. Provider business mailing address

4105 CRAWFORD AVE PO BOX 1067
NORTHERN CAMBRIA PA
15714-1341
US

V. Phone/Fax

Practice location:
  • Phone: 814-948-6720
  • Fax: 814-948-4933
Mailing address:
  • Phone: 814-948-6720
  • Fax: 814-948-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP412829L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP412829L
License Number StatePA

VIII. Authorized Official

Name: MR. ROBERT H KERR SR.
Title or Position: CO OWNER
Credential: RPH
Phone: 814-948-6720