Provider Demographics
NPI:1508051483
Name:WEAVER, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:WEAVER
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 1:334 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763
Mailing Address - Country:US
Mailing Address - Phone:701-627-2410
Mailing Address - Fax:701-627-2400
Practice Address - Street 1:334 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763
Practice Address - Country:US
Practice Address - Phone:701-627-2410
Practice Address - Fax:701-627-2400
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND1208183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician