Provider Demographics
NPI:1558793463
Name:LOPEZ LEAL, CARLOS BERNARDO (RPH)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:BERNARDO
Last Name:LOPEZ LEAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2083 GEORGIAN WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3052
Mailing Address - Country:US
Mailing Address - Phone:859-402-0442
Mailing Address - Fax:
Practice Address - Street 1:2083 GEORGIAN WAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3052
Practice Address - Country:US
Practice Address - Phone:859-402-0442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY016415OtherKENTUCKY BOARD OF PHARMACY