Provider Demographics
NPI:1740398106
Name:WEATHERWAX FAMILY PHARMACIES INC
Entity Type:Organization
Organization Name:WEATHERWAX FAMILY PHARMACIES INC
Other - Org Name:WEATHERWAX FAMILY PHARMACIES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEATHERWAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-592-8505
Mailing Address - Street 1:210 HINCKLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5313
Mailing Address - Country:US
Mailing Address - Phone:517-784-3184
Mailing Address - Fax:517-936-2917
Practice Address - Street 1:210 HINCKLEY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-5313
Practice Address - Country:US
Practice Address - Phone:517-784-3184
Practice Address - Fax:517-936-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010007363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2306214OtherOTHER ID NUMBER
MI2306214Medicaid
MI2306214Medicaid