Healthcare Provider Details

I. General information

NPI: 1881601706
Provider Name (Legal Business Name): F.E. LESLIE DRUGGIST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MAIN ST
VINEYARD HAVEN MA
02568-5402
US

IV. Provider business mailing address

PO BOX 417
VINEYARD HAVEN MA
02568-0417
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-1010
  • Fax: 508-693-6229
Mailing address:
  • Phone: 508-693-1010
  • Fax: 508-693-6229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3302
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3302
License Number StateMA

VIII. Authorized Official

Name: DAVID WARREN HOLMBERG
Title or Position: STORE MANAGER / CPHT-ADV
Credential: CPHT-ADV
Phone: 508-693-1010