Provider Demographics
NPI:1215533054
Name:BAE, LEON K (PHARMD)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:K
Last Name:BAE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PEBBLE HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4804
Mailing Address - Country:US
Mailing Address - Phone:832-515-9675
Mailing Address - Fax:
Practice Address - Street 1:1250 S WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5120
Practice Address - Country:US
Practice Address - Phone:409-381-8396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist