Provider Demographics
NPI:1003878513
Name:JOHNSON, LESLIE DIANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E CHAUTAUQUA ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1017
Mailing Address - Country:US
Mailing Address - Phone:716-753-3200
Mailing Address - Fax:716-753-3206
Practice Address - Street 1:99 E CHAUTAUQUA ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-1017
Practice Address - Country:US
Practice Address - Phone:716-753-3200
Practice Address - Fax:716-753-3206
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02316558Medicaid