Provider Demographics
NPI:1487628970
Name:LEEDOM, LAUREN ELIZABETH (LISA) (RPH, MBA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH (LISA)
Last Name:LEEDOM
Suffix:
Gender:F
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17273 STATE ROUTE 104
Mailing Address - Street 2:VA MEDICAL CENTER BUILDING 31 ROOM 200 (119)
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8608
Mailing Address - Country:US
Mailing Address - Phone:740-773-1141
Mailing Address - Fax:740-772-7199
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:VA MEDICAL CENTER BUILDING 31 ROOM 200 (119)
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8608
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:740-772-7199
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-13455183500000X
MI5302024014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist