Provider Demographics
NPI:1184405946
Name:WEAVER, WYATT COLE (PHARMD, MBA)
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:COLE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 PROVIDENCE FARM LN APT 6102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-7236
Mailing Address - Country:US
Mailing Address - Phone:980-416-2765
Mailing Address - Fax:
Practice Address - Street 1:11135 GOLF LINKS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-7801
Practice Address - Country:US
Practice Address - Phone:704-303-8626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist