Healthcare Provider Details

I. General information

NPI: 1134840481
Provider Name (Legal Business Name): JESSICA ANN LEIBOLD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1956 HIGHWAY 180 E
SILVER CITY NM
88061-7781
US

IV. Provider business mailing address

2311 RANCH CLUB RD
SILVER CITY NM
88061-7807
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-0133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00009711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: