Provider Demographics
NPI:1477168433
Name:LEIVO, FRED
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:LEIVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:CARPINTERIA
Mailing Address - State:CA
Mailing Address - Zip Code:93013-2415
Mailing Address - Country:US
Mailing Address - Phone:805-689-3578
Mailing Address - Fax:
Practice Address - Street 1:202 E OJAI AVE
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-2737
Practice Address - Country:US
Practice Address - Phone:805-646-7272
Practice Address - Fax:805-646-1614
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist