Provider Demographics
NPI:1619714011
Name:WATZIG, MIRANDA LYNN (PHARMD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:WATZIG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4866 SE ANTELOPE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-5499
Mailing Address - Country:US
Mailing Address - Phone:503-305-0633
Mailing Address - Fax:
Practice Address - Street 1:406 MCCLAINE ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1921
Practice Address - Country:US
Practice Address - Phone:503-873-8391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0020111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist