Provider Demographics
NPI:1154604577
Name:LEATHERS, EDWARD R (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:R
Last Name:LEATHERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-2843
Mailing Address - Country:US
Mailing Address - Phone:256-383-0896
Mailing Address - Fax:
Practice Address - Street 1:1801 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2843
Practice Address - Country:US
Practice Address - Phone:256-383-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003583Medicaid