MEDICARE: KENNETH LEARY 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	0202206877	VA

General Provider Information

NPI Number	:	1649502980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH LEARY RPH

Provider Business Mailing Address
First Line	:	5007 VICTORY BLVD
Second Line	:
City	:	TABB
State	:	VA
Zip	:	23693-5606
Country	:	US
Telephone Number	:	757-874-1245
Fax Number	:	757-877-6315

Provider Business Practice Location Address
First Line	:	5007 VICTORY BLVD
Second Line	:
City	:	TABB
State	:	VA
Zip	:	23693-5606
Country	:	US
Telephone Number	:	757-874-1245
Fax Number	:	757-877-6315

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

Provider Enumeration Date	:	02/11/2010
Last Update Date	:	02/11/2010

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