Provider Demographics
NPI:1477782027
Name:LEAVINE, KATIE M (RPH)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:LEAVINE
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 1:288 CORNELIA ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1730 FRONT ST
Practice Address - Street 2:
Practice Address - City:KEESEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-3618
Practice Address - Country:US
Practice Address - Phone:518-834-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist