Provider Demographics
NPI:1699375535
Name:CHASTAIN, LESLIE G
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MILWARD DR
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-8080
Mailing Address - Country:US
Mailing Address - Phone:859-338-8914
Mailing Address - Fax:
Practice Address - Street 1:1000 BYPASS N
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-9462
Practice Address - Country:US
Practice Address - Phone:502-839-1482
Practice Address - Fax:502-839-4268
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist