Provider Demographics
NPI:1063012813
Name:WEBER, ERICA DIANE
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:DIANE
Last Name:WEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E JASPER LN
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-8020
Mailing Address - Country:US
Mailing Address - Phone:618-553-2627
Mailing Address - Fax:
Practice Address - Street 1:108 KYDEN DRIVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441
Practice Address - Country:US
Practice Address - Phone:217-826-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.301875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist