Provider Demographics
NPI:1215505474
Name:MALL, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:MALL
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 1:25 POST RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4781
Mailing Address - Country:US
Mailing Address - Phone:518-218-1772
Mailing Address - Fax:518-389-4224
Practice Address - Street 1:25 POST RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4781
Practice Address - Country:US
Practice Address - Phone:518-218-1772
Practice Address - Fax:518-389-4224
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist