Provider Demographics
NPI:1215360185
Name:LEISENTRITT, MARY FLORENCE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:FLORENCE
Last Name:LEISENTRITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SHAPLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1401
Mailing Address - Country:US
Mailing Address - Phone:207-438-9079
Mailing Address - Fax:207-439-0119
Practice Address - Street 1:15 SHAPLEIGH RD
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1401
Practice Address - Country:US
Practice Address - Phone:207-438-9079
Practice Address - Fax:207-439-0119
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist