Provider Demographics
NPI:1285355529
Name:WEATHERSPOON, JOSEPH (PHARMD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:WEATHERSPOON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2202
Mailing Address - Country:US
Mailing Address - Phone:208-452-8700
Mailing Address - Fax:208-452-8701
Practice Address - Street 1:1210 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2202
Practice Address - Country:US
Practice Address - Phone:208-452-8700
Practice Address - Fax:208-452-8701
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist