Provider Demographics
NPI:1376816389
Name:GRAHAM, LEROY CLARENCE (RPH)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:CLARENCE
Last Name:GRAHAM
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 1:5322 W. 141ST TERR
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-1157
Mailing Address - Country:US
Mailing Address - Phone:913-608-5411
Mailing Address - Fax:
Practice Address - Street 1:125 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3329
Practice Address - Country:US
Practice Address - Phone:816-732-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO027882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18350000XOtherPHARMACIST