Healthcare Provider Details

I. General information

NPI: 1609605443
Provider Name (Legal Business Name): LOGAN WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 RIVER VISTA PL STE 101
TWIN FALLS ID
83301-3019
US

IV. Provider business mailing address

247 RIVER VISTA PL STE 101
TWIN FALLS ID
83301-3019
US

V. Phone/Fax

Practice location:
  • Phone: 208-329-8563
  • Fax:
Mailing address:
  • Phone: 901-917-1492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number12342981-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: