Provider Demographics
NPI:1609320753
Name:WEISS, PEGGY
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:WEISS
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 1:210 MAYHEW DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1311
Mailing Address - Country:US
Mailing Address - Phone:917-716-4939
Mailing Address - Fax:
Practice Address - Street 1:36 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:SOUTH FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12779-5804
Practice Address - Country:US
Practice Address - Phone:917-716-4939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0049311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist