Provider Demographics
NPI:1457622508
Name:LEATH, MARK CORNELIUS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CORNELIUS
Last Name:LEATH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:CORNELIUS
Other - Last Name:LEATH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:10960 MYRTLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3104
Mailing Address - Country:US
Mailing Address - Phone:772-370-3045
Mailing Address - Fax:
Practice Address - Street 1:2015 US HIGHWAY 441 N
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-1901
Practice Address - Country:US
Practice Address - Phone:863-763-1952
Practice Address - Fax:561-472-0390
Is Sole Proprietor?:No
Enumeration Date:2012-01-21
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 17593183500000X
FLPS17593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist