MEDICARE: WATERTOWN PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	261954	MN
2	3336L0003X	Long Term Care Pharmacy	261954	MN
3	3336C0003X	Community/Retail Pharmacy	261954	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720013279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERTOWN PHARMACY LLC

Provider Business Mailing Address
First Line	:	204 LEWIS AVE S
Second Line	:	SUITE 101
City	:	WATERTOWN
State	:	MN
Zip	:	55388-4500
Country	:	US
Telephone Number	:	952-955-2153
Fax Number	:	952-955-3067

Provider Business Practice Location Address
First Line	:	204 LEWIS AVE S
Second Line	:	SUITE 101
City	:	WATERTOWN
State	:	MN
Zip	:	55388-4500
Country	:	US
Telephone Number	:	952-955-2153
Fax Number	:

Authorized Official
Title or Position	:	CHIEF MANAGER
Name	:	ROSEMARY LOUISE ROSDAHL
Credential	:	RPH
Telephone Number	:	952-955-2153

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	04/13/2022

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Directions to “WATERTOWN PHARMACY LLC ” Practice Location

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