MEDICARE: MRS. LESLIE SHADE RPH

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	183500000X	Pharmacist	03-1-09852	OH

General Provider Information

NPI Number	:	1548365687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESLIE SHADE RPH

Provider Business Mailing Address
First Line	:	5165 DAVID RD
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-9302
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5770 KARL RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-3604
Country	:	US
Telephone Number	:	614-847-3784
Fax Number	:

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	07/08/2007

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