Provider Demographics
NPI:1285864819
Name:TEAGUE, LESLIE JANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:JANN
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:126 MISSOURI AVE
Mailing Address - Street 2:GLWACH PHARMACY
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8952
Mailing Address - Country:US
Mailing Address - Phone:573-596-0515
Mailing Address - Fax:573-596-0405
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:GLWACH PHARMACY
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-0515
Practice Address - Fax:573-596-0405
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist