Provider Demographics
NPI:1639780521
Name:LEIDEN, KELLY JEANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEANNE
Last Name:LEIDEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LA BRANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5309
Mailing Address - Country:US
Mailing Address - Phone:601-469-7372
Mailing Address - Fax:
Practice Address - Street 1:2601 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5167
Practice Address - Country:US
Practice Address - Phone:228-497-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-14986183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist