Provider Demographics
NPI:1871193359
Name:LEAL, MADELINE LAURA IRENE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:LAURA IRENE
Last Name:LEAL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SUPERCENTER DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-8190
Mailing Address - Country:US
Mailing Address - Phone:573-635-3877
Mailing Address - Fax:573-635-6520
Practice Address - Street 1:401 SUPERCENTER DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-8190
Practice Address - Country:US
Practice Address - Phone:573-635-3877
Practice Address - Fax:573-635-6520
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019025935183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist