MEDICARE: JOHN WALLACE WEIH RPH

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	5302022343	MI

General Provider Information

NPI Number	:	1871616060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WALLACE WEIH RPH

Provider Business Mailing Address
First Line	:	4010 HOLIDAY NORTH CT
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3763
Country	:	US
Telephone Number	:	231-938-3316
Fax Number	:

Provider Business Practice Location Address
First Line	:	3850 N LONG LAKE RD
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-9601
Country	:	US
Telephone Number	:	231-947-2880
Fax Number	:	231-947-2907

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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