Provider Demographics
NPI:1497956478
Name:GLEESON, CHARLES LEROY (RP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEROY
Last Name:GLEESON
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9889 CR 29
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008
Mailing Address - Country:US
Mailing Address - Phone:402-426-3581
Mailing Address - Fax:
Practice Address - Street 1:9889 CR 29
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008
Practice Address - Country:US
Practice Address - Phone:402-426-3581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist