Provider Demographics
NPI:1417098559
Name:LESLIE, TERESA (RPH)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 UNIVERSITY DR STE 100
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1080
Practice Address - Country:US
Practice Address - Phone:606-886-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist