MEDICARE: KENNETH WEAVER PHARM.D

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	183500000X	Pharmacist	26427	NC

General Provider Information

NPI Number	:	1164974218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WEAVER PHARM.D

Provider Business Mailing Address
First Line	:	1361 LAKE PARK BLVD N
Second Line	:
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-3946
Country	:	US
Telephone Number	:	910-458-4172
Fax Number	:

Provider Business Practice Location Address
First Line	:	1361 LAKE PARK BLVD N
Second Line	:
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-3946
Country	:	US
Telephone Number	:	910-458-4172
Fax Number	:

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

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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