Provider Demographics
NPI:1205142759
Name:PETERSON, LESLIE A (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 BIRD AVE
Mailing Address - Street 2:SUITE#5PMB282
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4607
Mailing Address - Country:US
Mailing Address - Phone:242-332-3358
Mailing Address - Fax:
Practice Address - Street 1:2829 BIRD AVE
Practice Address - Street 2:SUITE#5PMB282
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4607
Practice Address - Country:US
Practice Address - Phone:242-332-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-22
Last Update Date:2010-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38537183500000X
AZS004529183500000X
CA25102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist