Provider Demographics
NPI:1912004821
Name:LEECH, ROBERT WILLIAM JR (PD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:LEECH
Suffix:JR
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:AR
Mailing Address - Zip Code:71667
Mailing Address - Country:US
Mailing Address - Phone:870-628-4263
Mailing Address - Fax:870-628-4926
Practice Address - Street 1:109 DREW ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667
Practice Address - Country:US
Practice Address - Phone:870-628-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist