Provider Demographics
NPI:1437337151
Name:BRUNER, LEIGH FORD (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:LEIGH
Middle Name:FORD
Last Name:BRUNER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 INDIAN MOUNDS RD
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-4407
Mailing Address - Country:US
Mailing Address - Phone:229-724-2190
Mailing Address - Fax:229-723-8707
Practice Address - Street 1:90 COURT SQ
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2340
Practice Address - Country:US
Practice Address - Phone:229-723-3441
Practice Address - Fax:229-723-8707
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020815183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA020815OtherGA PHARMACIST LICENSE