Basic Information
| Provider Information | |||||||||
| NPI: | 1114312014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4430 MISSOURI AVE | ||||||||
| Address2: | PHARMACY DIVISION | ||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654739098 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4430 MISSOURI AVE | ||||||||
| Address2: | PHARMACY DIVISION | ||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654739098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735960514 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 03/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | RP448887 | PA | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.