Healthcare Provider Details

I. General information

NPI: 1902400120
Provider Name (Legal Business Name): LESLIE LYNN LEACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2020
Last Update Date: 11/29/2020
Certification Date: 11/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 E MAIN ST
JACKSON OH
45640-1758
US

IV. Provider business mailing address

67 LUTHER JONES RD
JACKSON OH
45640-9700
US

V. Phone/Fax

Practice location:
  • Phone: 740-286-6401
  • Fax: 740-286-4069
Mailing address:
  • Phone: 740-395-3429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03119123
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: