Provider Demographics
NPI:1538803374
Name:WEAVER, WADE ALAN
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:ALAN
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927-4921
Mailing Address - Country:US
Mailing Address - Phone:479-675-3900
Mailing Address - Fax:479-675-5909
Practice Address - Street 1:1531 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927-4921
Practice Address - Country:US
Practice Address - Phone:479-675-3900
Practice Address - Fax:479-675-5909
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD157641835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist