Provider Demographics
NPI:1659692309
Name:WELLER, DAVID JACK (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JACK
Last Name:WELLER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 MUKILTEO SPEEDWAY
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5432
Mailing Address - Country:US
Mailing Address - Phone:425-514-0620
Mailing Address - Fax:425-348-3041
Practice Address - Street 1:11700 MUKILTEO SPEEDWAY
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5432
Practice Address - Country:US
Practice Address - Phone:425-514-0620
Practice Address - Fax:425-348-3041
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00009143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist