Provider Demographics
NPI:1790373249
Name:SLUIS, LEAH MARIE
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:SLUIS
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 1:2187 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3014
Mailing Address - Country:US
Mailing Address - Phone:763-234-9716
Mailing Address - Fax:
Practice Address - Street 1:2187 4TH ST
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3094
Practice Address - Country:US
Practice Address - Phone:651-429-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist