Provider Demographics
NPI:1467000877
Name:SHORAGA, LESLIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ELIZABETH
Last Name:SHORAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5207
Mailing Address - Country:US
Mailing Address - Phone:618-997-2021
Mailing Address - Fax:618-997-2634
Practice Address - Street 1:2802 OUTER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5207
Practice Address - Country:US
Practice Address - Phone:618-997-2021
Practice Address - Fax:618-997-2634
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-040366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist