Provider Demographics
NPI:1114251741
Name:DANIEL, LESLIE SHANE (RPH)
Entity Type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:SHANE
Last Name:DANIEL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2214
Mailing Address - Country:US
Mailing Address - Phone:817-336-0754
Mailing Address - Fax:
Practice Address - Street 1:431 FULTON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2214
Practice Address - Country:US
Practice Address - Phone:817-336-0754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist