Provider Demographics
NPI:1548272859
Name:WEISS, JUDITH L (RPH)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:WEISS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-2324
Mailing Address - Country:US
Mailing Address - Phone:618-344-5169
Mailing Address - Fax:
Practice Address - Street 1:228 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-3016
Practice Address - Country:US
Practice Address - Phone:618-345-2880
Practice Address - Fax:618-345-0899
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist