Provider Demographics
NPI:1972103083
Name:TODD, LESLEY BROWN
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:BROWN
Last Name:TODD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:ASHTON
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:628 CROWN POINT DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5303A WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-2800
Practice Address - Country:US
Practice Address - Phone:762-383-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42643183500000X
GARPH031689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist