Healthcare Provider Details

I. General information

NPI: 1104282318
Provider Name (Legal Business Name): RANDOLPH J WEAVER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7181 STATE ROUTE 54
BATH NY
14810-9502
US

IV. Provider business mailing address

7181 STATE ROUTE 54
BATH NY
14810
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-9039
  • Fax:
Mailing address:
  • Phone: 607-664-9039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number034106
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RANDOLPH WEAVER
Title or Position: OWNER/RPH
Credential:
Phone: 607-664-9039