Basic Information
| Provider Information | |||||||||
| NPI: | 1740655620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONOV | ||||||||
| FirstName: | DMITRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHRAM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 GRANDE VISTA DR STE 725 | ||||||||
| Address2: | |||||||||
| City: | NEWBURY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913201131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7477770023 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4601 DALE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097355000 | ||||||||
| FaxNumber: | 2098252405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2015 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 18108 | NV | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | 63653 | CA | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.