=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700876422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BYRD WATSON DRUG CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2005
-----------------------------------------------------
Last Update Date | 12/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1071 W BROADWAY
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-532-2200
-----------------------------------------------------
Fax | 618-533-0566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1071 W BROADWAY
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-532-2200
-----------------------------------------------------
Fax | 618-533-0566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRES
-----------------------------------------------------
Name | MR. WESLEY N BREEZE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 618-532-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------