MEDICARE: WANDA K WEATHERBY PHARMD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	13282	NC

General Provider Information

NPI Number	:	1043372659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA K WEATHERBY PHARMD

Provider Business Mailing Address
First Line	:	1060 GAFFNEY RD
Second Line	:	BLDG 4076
City	:	FT WAINWRIGHT
State	:	AK
Zip	:	99703-7440
Country	:	US
Telephone Number	:	907-361-5435
Fax Number	:	907-361-4838

Provider Business Practice Location Address
First Line	:	1060 GAFFNEY RD
Second Line	:	BLDG 4076
City	:	FT WAINWRIGHT
State	:	AK
Zip	:	99703-5002
Country	:	US
Telephone Number	:	907-361-5435
Fax Number	:	907-361-4838

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	10/26/2016

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