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General NPI Number Information
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NPI Number | 1114969730
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Entity Type | Organization
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Legal Business Name | WATERMONT PHARMACY
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 04/22/2011
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Provider Practice Location Address
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Address Line | 4900 WATERLOO RD # A
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-6664
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Country | US
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Telephone | 410-465-0552
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Fax | 410-465-0553
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Provider Business Mailing Address
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Address Line | 4900 WATERLOO RD # A
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-6664
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Country | US
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Telephone | 410-465-0552
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Fax | 410-465-0553
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Authorized Official
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Title or Position | OWNER PHARMACIST
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Name | JODI LARE
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Credential | RPH
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Telephone | 410-465-0552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | P00820
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License Number State | MD
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