Provider Demographics
NPI:1285356592
Name:GRANBERRY, LESLIE JERALD JR
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JERALD
Last Name:GRANBERRY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20500 SW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2296
Mailing Address - Country:US
Mailing Address - Phone:305-235-4325
Mailing Address - Fax:
Practice Address - Street 1:20500 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-2296
Practice Address - Country:US
Practice Address - Phone:305-235-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist