Provider Demographics
NPI:1487126991
Name:WATT, JOHNATHAN
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:WATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:WATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 410106
Mailing Address - Street 2:
Mailing Address - City:PINESDALE
Mailing Address - State:MT
Mailing Address - Zip Code:59841-0106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2086 US HIGHWAY 93 N STE 110
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:MT
Practice Address - Zip Code:59875-9209
Practice Address - Country:US
Practice Address - Phone:406-529-6182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-47285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist