Provider Demographics
NPI:1528684750
Name:WEAVER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HALL RD
Mailing Address - Street 2:
Mailing Address - City:SEAGOVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75159-2915
Mailing Address - Country:US
Mailing Address - Phone:972-287-1680
Mailing Address - Fax:972-287-2269
Practice Address - Street 1:125 HALL RD
Practice Address - Street 2:
Practice Address - City:SEAGOVILLE
Practice Address - State:TX
Practice Address - Zip Code:75159-2915
Practice Address - Country:US
Practice Address - Phone:972-287-1680
Practice Address - Fax:972-287-2269
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36870OtherTEXAS STATE BOARD OF PHARMACY