MEDICARE: MS. SUSAN GRACE LECKBAND RPH, BCPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1300X	Psychiatric Pharmacist	47907	CA

General Provider Information

NPI Number	:	1306843206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN GRACE LECKBAND RPH, BCPP

Provider Business Mailing Address
First Line	:	3350 LA JOLLA VILLAGE DR
Second Line	:	119
City	:	LA JOLLA
State	:	CA
Zip	:	92037-1806
Country	:	US
Telephone Number	:	858-552-8585
Fax Number	:	858-552-4336

Provider Business Practice Location Address
First Line	:	3350 LA JOLLA VILLAGE DR
Second Line	:	119
City	:	LA JOLLA
State	:	CA
Zip	:	92037-1806
Country	:	US
Telephone Number	:	858-552-8585
Fax Number	:	858-552-4336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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