Provider Demographics
NPI:1285624197
Name:GREGERSEN, LESLIE ANNE (RPH)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANNE
Last Name:GREGERSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3738 OAKRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5868
Mailing Address - Country:US
Mailing Address - Phone:801-397-0788
Mailing Address - Fax:801-213-9160
Practice Address - Street 1:1525 W 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1401
Practice Address - Country:US
Practice Address - Phone:801-213-9150
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT150873-1719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist