Provider Demographics
NPI:1124396650
Name:LEIST, DANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DANE
Middle Name:
Last Name:LEIST
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 1:2206 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-2241
Mailing Address - Country:US
Mailing Address - Phone:920-793-8352
Mailing Address - Fax:
Practice Address - Street 1:2206 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-2241
Practice Address - Country:US
Practice Address - Phone:920-793-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16249-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist