Healthcare Provider Details

I. General information

NPI: 1912004821
Provider Name (Legal Business Name): ROBERT WILLIAM LEECH JR. PD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 DREW ST
STAR CITY AR
71667
US

IV. Provider business mailing address

PO BOX 479
STAR CITY AR
71667
US

V. Phone/Fax

Practice location:
  • Phone: 870-628-4263
  • Fax:
Mailing address:
  • Phone: 870-628-4263
  • Fax: 870-628-4926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5555
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: