=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407867062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 05/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MAIN ST
-----------------------------------------------------
City | RIPLEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45167-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-392-4020
-----------------------------------------------------
Fax | 937-392-4078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MAIN ST
-----------------------------------------------------
City | RIPLEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45167-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-392-4020
-----------------------------------------------------
Fax | 937-392-4078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT WATERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-392-4020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 020976000
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------