Provider Demographics
NPI:1255935466
Name:ELLIOTT DEMETRIUS, LESA
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:
Last Name:ELLIOTT DEMETRIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13767 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3967
Mailing Address - Country:US
Mailing Address - Phone:954-649-0965
Mailing Address - Fax:
Practice Address - Street 1:1200 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4524
Practice Address - Country:US
Practice Address - Phone:305-825-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist