Provider Demographics
NPI:1861680753
Name:WEAVER, BRIAN (PHARM D)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 ADDISON AVE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5224
Mailing Address - Country:US
Mailing Address - Phone:208-734-2660
Mailing Address - Fax:208-736-3872
Practice Address - Street 1:1139 ADDISON AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5224
Practice Address - Country:US
Practice Address - Phone:208-734-2660
Practice Address - Fax:208-736-3872
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist