Provider Demographics
NPI:1366692782
Name:SISSON, LESLIE DIANE (RPH)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DIANE
Last Name:SISSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:DIANE
Other - Last Name:SISSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:2795 RITTER DR
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-8515
Mailing Address - Country:US
Mailing Address - Phone:304-573-1114
Mailing Address - Fax:
Practice Address - Street 1:2795 RITTER DR
Practice Address - Street 2:
Practice Address - City:SHADY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25918
Practice Address - Country:US
Practice Address - Phone:304-573-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist