Provider Demographics
NPI:1023157070
Name:WATSONS DRUG STORE INC
Entity type:Organization
Organization Name:WATSONS DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BART
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDIORARO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-664-3600
Mailing Address - Street 1:214 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1736
Mailing Address - Country:US
Mailing Address - Phone:618-664-3600
Mailing Address - Fax:618-664-2820
Practice Address - Street 1:214 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1736
Practice Address - Country:US
Practice Address - Phone:618-664-3600
Practice Address - Fax:618-664-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
IL0540161173336C0003X
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023334OtherPK
1480374OtherOTHER ID NUMBER
IL=========001Medicaid
5867770001Medicare NSC