Basic Information
| Provider Information | |||||||||
| NPI: | 1487628970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEEDOM | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ELIZABETH (LISA) | ||||||||
| NamePrefix: | |||||||||
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| Credential: | R.PH., M.B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17273 STATE ROUTE 104 | ||||||||
| Address2: | VA MEDICAL CENTER BUILDING 31 ROOM 200 (119) | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
| FaxNumber: | 7407727199 | ||||||||
| Practice Location | |||||||||
| Address1: | 17273 STATE ROUTE 104 | ||||||||
| Address2: | VA MEDICAL CENTER BUILDING 31 ROOM 200 (119) | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
| FaxNumber: | 7407727199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/27/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03-3-13455 | OH | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 5302024014 | MI | N | Pharmacy Service Providers | Pharmacist |
No ID Information.