Provider Demographics
NPI:1588265169
Name:LECLOUX, ERIC JOHN (PHARM D)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:LECLOUX
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2753 BLUE SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4507
Mailing Address - Country:US
Mailing Address - Phone:920-680-5570
Mailing Address - Fax:
Practice Address - Street 1:125 SCHOOL CREEK TRL
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1095
Practice Address - Country:US
Practice Address - Phone:920-845-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15922-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist