1952303455 NPI number — DR. LEISA L MARSHALL PHARM.D., CGP

Table of content: DR. LEISA L MARSHALL PHARM.D., CGP (NPI 1952303455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952303455 NPI number — DR. LEISA L MARSHALL PHARM.D., CGP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
LEISA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D., CGP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952303455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3094 FARMINGTON DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-4703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-435-7034
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 E WEST CONNECTOR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-819-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  014567 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com