Provider Demographics
NPI:1952712440
Name:WEATHERSTON, ROY (RPH)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:WEATHERSTON
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 1:85 E SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-9683
Mailing Address - Country:US
Mailing Address - Phone:208-356-7746
Mailing Address - Fax:
Practice Address - Street 1:490 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1654
Practice Address - Country:US
Practice Address - Phone:208-542-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-4245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist