Provider Demographics
NPI:1689942724
Name:LEICH, TIMOTHY ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:LEICH
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 1:424 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-2130
Mailing Address - Country:US
Mailing Address - Phone:217-935-1357
Mailing Address - Fax:217-935-5952
Practice Address - Street 1:424 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-2130
Practice Address - Country:US
Practice Address - Phone:217-935-1357
Practice Address - Fax:217-935-5952
Is Sole Proprietor?:No
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051286344OtherPHARMACIST LICENSE