Provider Demographics
NPI:1114273539
Name:DARK, LEO M (PHARMD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:M
Last Name:DARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3177 SETTING SUN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5211
Mailing Address - Country:US
Mailing Address - Phone:989-497-9411
Mailing Address - Fax:
Practice Address - Street 1:3177 SETTING SUN BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-5211
Practice Address - Country:US
Practice Address - Phone:989-497-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024160183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist