Provider Demographics
NPI:1477132488
Name:LEONIDA, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEONIDA
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 1:112 LEXINGTON AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1610
Mailing Address - Country:US
Mailing Address - Phone:201-920-2506
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND STREET
Practice Address - Street 2:PHARMACY DEPARTMENT, FLOOR 2
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302
Practice Address - Country:US
Practice Address - Phone:201-915-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI038732001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist