Provider Demographics
NPI:1043496391
Name:LEAGUE, MICKEY A (PHARMACIST)
Entity Type:Individual
Prefix:MRS
First Name:MICKEY
Middle Name:A
Last Name:LEAGUE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:MRS
Other - First Name:MICKEY
Other - Middle Name:ALLEN
Other - Last Name:LEAGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:3621 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3411
Mailing Address - Country:US
Mailing Address - Phone:252-937-6030
Mailing Address - Fax:252-443-6510
Practice Address - Street 1:3621 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3411
Practice Address - Country:US
Practice Address - Phone:252-937-6030
Practice Address - Fax:252-443-6510
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist