Provider Demographics
NPI:1902982622
Name:LEATH & LEATH INC
Entity Type:Organization
Organization Name:LEATH & LEATH INC
Other - Org Name:LEATH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:LEATH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:772-461-6330
Mailing Address - Street 1:1727 OKEECHOBEE RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-3945
Mailing Address - Country:US
Mailing Address - Phone:772-461-6330
Mailing Address - Fax:772-461-1798
Practice Address - Street 1:1727 OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-3945
Practice Address - Country:US
Practice Address - Phone:772-461-6330
Practice Address - Fax:772-461-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH9856332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109697400Medicaid
FL0775700001Medicare NSC