Provider Demographics
NPI:1578955191
Name:MADDOCK, LESLIE (RPH)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MADDOCK
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 1:8143 LOVERS LANE RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:47016-9711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:516 W 30TH ST
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2502
Practice Address - Country:US
Practice Address - Phone:765-825-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03225280183500000X
IN26021044A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist