Provider Demographics
NPI:1922639103
Name:LEACH, ROBERT BLAKE
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BLAKE
Last Name:LEACH
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 1:960 E TRI COUNTY BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVER SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37840-1820
Mailing Address - Country:US
Mailing Address - Phone:865-432-6337
Mailing Address - Fax:
Practice Address - Street 1:960 E TRI COUNTY BLVD
Practice Address - Street 2:
Practice Address - City:OLIVER SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37840-1820
Practice Address - Country:US
Practice Address - Phone:865-432-6337
Practice Address - Fax:865-432-6338
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000043370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist