Provider Demographics
NPI:1629417340
Name:LEACH, JEREMY I (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:I
Last Name:LEACH
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 1:1025 E HIGHWAY 72 BYP
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-7326
Mailing Address - Country:US
Mailing Address - Phone:573-783-6000
Mailing Address - Fax:573-783-6008
Practice Address - Street 1:1025 E HIGHWAY 72 BYP
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-7326
Practice Address - Country:US
Practice Address - Phone:573-783-6000
Practice Address - Fax:573-783-6008
Is Sole Proprietor?:No
Enumeration Date:2013-06-15
Last Update Date:2013-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005002685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6728630001Medicare NSC