Provider Demographics
NPI:1639433543
Name:WEATHERMON, LONNIE ROBERT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:ROBERT
Last Name:WEATHERMON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6151
Mailing Address - Country:US
Mailing Address - Phone:208-522-3572
Mailing Address - Fax:208-522-3066
Practice Address - Street 1:800 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6151
Practice Address - Country:US
Practice Address - Phone:208-522-3572
Practice Address - Fax:208-522-3066
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist