Provider Demographics
NPI:1063081818
Name:LEON, IRENE C
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:C
Last Name:LEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 LANTANA DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:874 E 41ST ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-2455
Practice Address - Country:US
Practice Address - Phone:305-693-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL196681835G0303X
FL19688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1659465342Medicaid