Provider Demographics
NPI:1629136460
Name:WOODY WEAVER PHARMACY
Entity Type:Organization
Organization Name:WOODY WEAVER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WOODROW
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-593-2533
Mailing Address - Street 1:2722 WEST GENTRY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702
Mailing Address - Country:US
Mailing Address - Phone:903-593-2533
Mailing Address - Fax:903-593-2555
Practice Address - Street 1:2722 WEST GENTRY PARKWAY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702
Practice Address - Country:US
Practice Address - Phone:903-593-2533
Practice Address - Fax:903-593-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130525Medicaid
4532936OtherNABP
AW4236611OtherDEA
AW4236611OtherDEA