Healthcare Provider Details

I. General information

NPI: 1497902381
Provider Name (Legal Business Name): WOODY WEAVER PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 E RUSK ST 101
JACKSONVILLE TX
75766-4992
US

IV. Provider business mailing address

PO BOX 130008
TYLER TX
75713-0008
US

V. Phone/Fax

Practice location:
  • Phone: 903-597-4363
  • Fax: 903-526-7617
Mailing address:
  • Phone: 903-597-4363
  • Fax: 903-526-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number0092940
License Number StateTX

VIII. Authorized Official

Name: COTY C CARNES
Title or Position: OWNER
Credential:
Phone: 903-597-4363