MEDICARE: LESLIE DIANE SISSON 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	5403	WV

General Provider Information

NPI Number	:	1366692782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE DIANE SISSON RPH

Provider Business Mailing Address
First Line	:	2795 RITTER DR
Second Line	:
City	:	SHADY SPRING
State	:	WV
Zip	:	25918-8515
Country	:	US
Telephone Number	:	304-573-1114
Fax Number	:

Provider Business Practice Location Address
First Line	:	2795 RITTER DR
Second Line	:
City	:	SHADY SPRING
State	:	WV
Zip	:	25918
Country	:	US
Telephone Number	:	304-573-1114
Fax Number	:

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

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	10/17/2019

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