Provider Demographics
NPI:1982056362
Name:LEIDER, CURTIS
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:
Last Name:LEIDER
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 1:109 DOTY ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:WI
Mailing Address - Zip Code:54940-9104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:291 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1604
Practice Address - Country:US
Practice Address - Phone:715-823-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18436-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist