Provider Demographics
NPI:1770185985
Name:WEAVER, JACOB THOMAS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-2815
Mailing Address - Country:US
Mailing Address - Phone:570-476-8834
Mailing Address - Fax:
Practice Address - Street 1:300 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-2815
Practice Address - Country:US
Practice Address - Phone:570-476-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453612183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist