Provider Demographics
NPI:1063721777
Name:LEO, THERESA (PHARMD, MS)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:LEO
Suffix:
Gender:F
Credentials:PHARMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 RAVINE DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-1129
Mailing Address - Country:US
Mailing Address - Phone:315-735-0895
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVE
Practice Address - Street 2:MC 85
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-7369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist