Provider Demographics
NPI:1972621787
Name:COSTELLO, CARMEN LEIGH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:LEIGH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9407 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64138-4214
Mailing Address - Country:US
Mailing Address - Phone:816-718-6022
Mailing Address - Fax:
Practice Address - Street 1:310 SW WARD RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-2445
Practice Address - Country:US
Practice Address - Phone:816-554-2211
Practice Address - Fax:816-554-2086
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005031064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist