Healthcare Provider Details

I. General information

NPI: 1164425658
Provider Name (Legal Business Name): LEO F. MALLARD RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CHESAPEAKE BEACH RD, EAST
OWINGS MD
20736
US

IV. Provider business mailing address

4750 CAMP ROOSEVELT DR
CHESAPEAKE BEACH MD
20732-3416
US

V. Phone/Fax

Practice location:
  • Phone: 301-855-2357
  • Fax:
Mailing address:
  • Phone: 301-855-2357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number07164
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: