Healthcare Provider Details

I. General information

NPI: 1215505474
Provider Name (Legal Business Name): LEAH MALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 POST RD
ALBANY NY
12205-4781
US

IV. Provider business mailing address

25 POST RD
ALBANY NY
12205-4781
US

V. Phone/Fax

Practice location:
  • Phone: 518-218-1772
  • Fax: 518-389-4224
Mailing address:
  • Phone: 518-218-1772
  • Fax: 518-389-4224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number066572
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: