Provider Demographics
NPI:1609217751
Name:WEITZEL, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:WEITZEL
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 1:640 WEST WILSON
Mailing Address - Street 2:APARTMENT 305
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703
Mailing Address - Country:US
Mailing Address - Phone:260-417-2069
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist