Provider Demographics
NPI:1710220926
Name:JOHNSON, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JOHNSON
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 1:300 PUPPY SMITH ST
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1455
Mailing Address - Country:US
Mailing Address - Phone:970-925-2728
Mailing Address - Fax:970-925-2728
Practice Address - Street 1:300 PUPPY SMITH ST
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611
Practice Address - Country:US
Practice Address - Phone:970-925-2728
Practice Address - Fax:970-544-4201
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist