1598775413 NPI number — BYRD-WATSON TIMES SQUARE DRUG CO

Table of content: JESSICA REINHOLD SWANSON DNP (NPI 1245584754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598775413 NPI number — BYRD-WATSON TIMES SQUARE DRUG CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BYRD-WATSON TIMES SQUARE DRUG CO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BYRD-WATSON PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598775413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62864-0024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-242-2800
Provider Business Mailing Address Fax Number:
618-242-6775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-244-5400
Provider Business Practice Location Address Fax Number:
618-244-5988
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREEZE
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER OF THE CORPORATION
Authorized Official Telephone Number:
618-244-5400

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  054009959 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054.009959 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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