Provider Demographics
NPI:1801496245
Name:BAKER, LESLIE A (RPH)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:BAKER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 BIRCHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6217
Mailing Address - Country:US
Mailing Address - Phone:618-581-9374
Mailing Address - Fax:
Practice Address - Street 1:610 WESLEY DR
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1894
Practice Address - Country:US
Practice Address - Phone:618-259-0293
Practice Address - Fax:618-259-8757
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist