Provider Demographics
NPI:1063186252
Name:MIJOS, LEANDRO
Entity type:Individual
Prefix:DR
First Name:LEANDRO
Middle Name:
Last Name:MIJOS
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 1:3980 VENTURE DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5077
Mailing Address - Country:US
Mailing Address - Phone:770-622-2317
Mailing Address - Fax:
Practice Address - Street 1:3980 VENTURE DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5077
Practice Address - Country:US
Practice Address - Phone:770-622-2317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist