Provider Demographics
NPI:1801911714
Name:WEAVER, TOMMY LYNN (RPH)
Entity type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:LYNN
Last Name:WEAVER
Suffix:
Gender:M
Credentials:RPH
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 230
Mailing Address - Street 2:
Mailing Address - City:WHEELER
Mailing Address - State:TX
Mailing Address - Zip Code:79096-0230
Mailing Address - Country:US
Mailing Address - Phone:806-826-5561
Mailing Address - Fax:806-826-5655
Practice Address - Street 1:109 WEST TEXAS STREET
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:TX
Practice Address - Zip Code:79096-0230
Practice Address - Country:US
Practice Address - Phone:806-826-5561
Practice Address - Fax:806-826-5655
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143204Medicaid
TX4576003OtherNCPDP
TX143204Medicaid