MEDICARE: LEO F. MALLARD RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	07164	MD

General Provider Information

NPI Number	:	1164425658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEO F. MALLARD RPH

Provider Business Mailing Address
First Line	:	4750 CAMP ROOSEVELT DR
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3416
Country	:	US
Telephone Number	:	301-855-2357
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 CHESAPEAKE BEACH RD, EAST
Second Line	:
City	:	OWINGS
State	:	MD
Zip	:	20736
Country	:	US
Telephone Number	:	301-855-2357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/08/2007

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