Provider Demographics
NPI:1821505553
Name:WEESE, MARK R (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:WEESE
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:PO BOX 692
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-0692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4321 FIR ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3049
Practice Address - Country:US
Practice Address - Phone:219-392-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022698A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist