Provider Demographics
NPI:1124165956
Name:WATTS CLINIC PHARMACY
Entity type:Organization
Organization Name:WATTS CLINIC PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSING & CREDENTIALING COORDINAT
Authorized Official - Prefix:MS
Authorized Official - First Name:DALILA
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-599-8181
Mailing Address - Street 1:10604 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4015
Mailing Address - Country:US
Mailing Address - Phone:714-599-8181
Mailing Address - Fax:714-599-8242
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:714-926-7131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY468693336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5615591OtherNCPDP NUMBER
CAPHY46869OtherSTATE LICENSE
CAPHA463330Medicaid