=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841261716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BBAD ENTERPRISES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 590 S MAIN ST SUITE A
-----------------------------------------------------
City | TEMPLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93465-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-434-5969
-----------------------------------------------------
Fax | 805-434-5967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 590 S MAIN ST SUITE A
-----------------------------------------------------
City | TEMPLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93465-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-434-5969
-----------------------------------------------------
Fax | 805-434-5967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRENT FORNEY WATSON
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 805-434-5969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHY43878
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------