MEDICARE: STEVEN LESLIE WEATHERWAX

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	5302021313	MI

General Provider Information

NPI Number	:	1710936851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN LESLIE WEATHERWAX

Provider Business Mailing Address
First Line	:	110 NICOLE DR
Second Line	:
City	:	BROOKLYN
State	:	MI
Zip	:	49230-9352
Country	:	US
Telephone Number	:	517-592-8026
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 N MAIN ST
Second Line	:
City	:	BROOKLYN
State	:	MI
Zip	:	49230-8979
Country	:	US
Telephone Number	:	517-592-8505
Fax Number	:	517-592-4043

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	07/08/2007

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Directions to “ STEVEN LESLIE WEATHERWAX ” Practice Location

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