Provider Demographics
NPI:1154603025
Name:MARTINO, LESHIA RENE
Entity type:Individual
Prefix:
First Name:LESHIA
Middle Name:RENE
Last Name:MARTINO
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 1:15035 WILLIAMSBURG ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7703
Mailing Address - Country:US
Mailing Address - Phone:734-285-2415
Mailing Address - Fax:
Practice Address - Street 1:1700 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2676
Practice Address - Country:US
Practice Address - Phone:734-675-2997
Practice Address - Fax:734-675-6695
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302410542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302410543OtherPHARMACIST LICENSE