Provider Demographics
NPI:1922638816
Name:LEIBOH, ALLAN
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:LEIBOH
Suffix:
Gender:M
Credentials:
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 109
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92263-0109
Mailing Address - Country:US
Mailing Address - Phone:760-567-6971
Mailing Address - Fax:
Practice Address - Street 1:425 S SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7663
Practice Address - Country:US
Practice Address - Phone:760-322-2784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist