Provider Demographics
NPI:1265747273
Name:WEISS, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WEISS
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 1:4747 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9377
Mailing Address - Country:US
Mailing Address - Phone:928-330-3704
Mailing Address - Fax:928-330-3707
Practice Address - Street 1:4747 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9377
Practice Address - Country:US
Practice Address - Phone:928-330-3704
Practice Address - Fax:928-330-3707
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS015632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist