Provider Demographics
NPI:1528242807
Name:WATTS, JASON EARL (PHARMD)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:EARL
Last Name:WATTS
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 1:150 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1443
Mailing Address - Country:US
Mailing Address - Phone:208-745-0267
Mailing Address - Fax:
Practice Address - Street 1:150 N STATE ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1443
Practice Address - Country:US
Practice Address - Phone:208-745-0267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-22
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6077183500000X, 1835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy