=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659388130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH GERARD WEAVER BS PHARMACY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7219 N LITCHFIELD RD
-----------------------------------------------------
City | LUKE AFB
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85309-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-856-7104
-----------------------------------------------------
Fax | 623-856-6120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16810 W TARA LN
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85388-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-476-2544
-----------------------------------------------------
Fax | 623-856-6120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202006440
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------