MEDICARE: WATTERS BROS DRUG STORE INC

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
2	333600000X	Pharmacy	PP412829L	PA
3	3336C0003X	Community/Retail Pharmacy	PP412829L	PA

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
2	0390963	OTHER	PA	PACE
3	3909631	OTHER		NASP

General Provider Information

NPI Number	:	1881670388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATTERS BROS DRUG STORE INC

Provider Business Mailing Address
First Line	:	4105 CRAWFORD AVE
Second Line	:	PO BOX 1067
City	:	NORTHERN CAMBRIA
State	:	PA
Zip	:	15714-1341
Country	:	US
Telephone Number	:	814-948-6720
Fax Number	:	814-948-4933

Provider Business Practice Location Address
First Line	:	4105 CRAWFORD AVE
Second Line	:
City	:	NORTHERN CAMBRIA
State	:	PA
Zip	:	15714-1341
Country	:	US
Telephone Number	:	814-948-6720
Fax Number	:	814-948-4933

Authorized Official
Title or Position	:	CO OWNER
Name	:	MR. ROBERT H KERR SR.
Credential	:	RPH
Telephone Number	:	814-948-6720

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	07/05/2013

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Directions to “WATTERS BROS DRUG STORE INC ” Practice Location

Language	Start Address	Practice Location

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