Provider Demographics
NPI:1649801218
Name:ANDERSON, LEONARD
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 N COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-8465
Mailing Address - Country:US
Mailing Address - Phone:478-414-2145
Mailing Address - Fax:
Practice Address - Street 1:2809 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-8465
Practice Address - Country:US
Practice Address - Phone:478-414-2145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0140391835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist