Provider Demographics
NPI:1669529137
Name:WATSON, BRENT FORNEY (RPH)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:FORNEY
Last Name:WATSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1493 PAMELA COURT
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON,
Mailing Address - State:CA
Mailing Address - Zip Code:93465
Mailing Address - Country:US
Mailing Address - Phone:805-434-5969
Mailing Address - Fax:805-434-5967
Practice Address - Street 1:590A S MAIN ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-5101
Practice Address - Country:US
Practice Address - Phone:805-434-5969
Practice Address - Fax:805-434-5967
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28264183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist