Provider Demographics
NPI:1225321649
Name:WEAVER, DALE R
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S. THIRD ST.
Mailing Address - Street 2:PO BOX 276
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH THIRD ST.
Practice Address - Street 2:
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-1108
Practice Address - Country:US
Practice Address - Phone:814-382-2380
Practice Address - Fax:814-382-8218
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP031999L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist