Provider Demographics
NPI:1861772717
Name:WATT, RANDAL LYNN (PHARMD)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:LYNN
Last Name:WATT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 PASEO DEL PUEBLO SUR STE A
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5998
Mailing Address - Country:US
Mailing Address - Phone:575-758-1203
Mailing Address - Fax:
Practice Address - Street 1:710 PASEO DEL PUEBLO SUR STE A
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5998
Practice Address - Country:US
Practice Address - Phone:575-758-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist