Provider Demographics
NPI:1396153904
Name:WATSON, SAMUEL MONTGOMERY (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MONTGOMERY
Last Name:WATSON
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 1:2641 42ND AVE SW APT 101
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4901
Mailing Address - Country:US
Mailing Address - Phone:913-269-8804
Mailing Address - Fax:
Practice Address - Street 1:3282 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5603
Practice Address - Country:US
Practice Address - Phone:360-876-0969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-27
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60475999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist