Provider Demographics
NPI:1659071025
Name:WEAVER, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
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 1:801 GLENWOOD RD APT 1
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-1623
Mailing Address - Country:US
Mailing Address - Phone:419-921-8025
Mailing Address - Fax:
Practice Address - Street 1:21991 STATE ROUTE 51 W
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1251
Practice Address - Country:US
Practice Address - Phone:419-855-8363
Practice Address - Fax:419-855-0123
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09214297183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician