Provider Demographics
NPI:1053054296
Name:WEAVERVILLE PHARMACY INC
Entity type:Organization
Organization Name:WEAVERVILLE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CFO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-987-6796
Mailing Address - Street 1:748 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3319
Mailing Address - Country:US
Mailing Address - Phone:530-698-0990
Mailing Address - Fax:530-698-0991
Practice Address - Street 1:60C SOUTH MINER STREET
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093
Practice Address - Country:US
Practice Address - Phone:530-698-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy