Provider Demographics
NPI:1730462136
Name:WECKERLIN, LESLIE DAWN (RPH)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DAWN
Last Name:WECKERLIN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 HAMPSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5315
Mailing Address - Country:US
Mailing Address - Phone:815-459-2614
Mailing Address - Fax:
Practice Address - Street 1:315 N ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-404-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.037688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist