MEDICARE: GRETCHEN ILER WEAVER R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1300X	Psychiatric Pharmacist	03112227	OH

General Provider Information

NPI Number	:	1366651770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETCHEN ILER WEAVER R.PH.

Provider Business Mailing Address
First Line	:	2708 WELSFORD RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3323
Country	:	US
Telephone Number	:	614-488-3852
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43223-1257
Country	:	US
Telephone Number	:	614-752-0133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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