Provider Demographics
NPI:1700481793
Name:LEGGE, ANTONY
Entity Type:Individual
Prefix:
First Name:ANTONY
Middle Name:
Last Name:LEGGE
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 1:3908 N STATE LINE AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1935
Mailing Address - Country:US
Mailing Address - Phone:870-772-0236
Mailing Address - Fax:
Practice Address - Street 1:3908 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1935
Practice Address - Country:US
Practice Address - Phone:870-772-0236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63771183500000X
ARPD12983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist