Provider Demographics
NPI:1336424381
Name:LEIDAL, AMY MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MARIE
Last Name:LEIDAL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 S IH 35
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-2713
Mailing Address - Country:US
Mailing Address - Phone:512-804-3203
Mailing Address - Fax:
Practice Address - Street 1:5015 S IH 35
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-2713
Practice Address - Country:US
Practice Address - Phone:512-804-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist