Provider Demographics
NPI:1164425658
Name:MALLARD, LEO F (RPH)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:F
Last Name:MALLARD
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 1:4750 CAMP ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE BEACH
Mailing Address - State:MD
Mailing Address - Zip Code:20732-3416
Mailing Address - Country:US
Mailing Address - Phone:301-855-2357
Mailing Address - Fax:
Practice Address - Street 1:15 CHESAPEAKE BEACH RD, EAST
Practice Address - Street 2:
Practice Address - City:OWINGS
Practice Address - State:MD
Practice Address - Zip Code:20736
Practice Address - Country:US
Practice Address - Phone:301-855-2357
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist