=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215548250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEO WALTER FIELDS JR. PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2020
-----------------------------------------------------
Last Update Date | 08/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 BLUE MOON XING
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-9797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-348-6027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1699 CHATHAM PKWY APT 1327A
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-7618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-403-1461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH032253
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------