Provider Demographics
NPI:1558965749
Name:LECKIE, TRISTAN (PARMD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:LECKIE
Suffix:
Gender:M
Credentials:PARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 HAMPTON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-5203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-2621
Practice Address - Country:US
Practice Address - Phone:540-745-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist