Provider Demographics
NPI:1538255955
Name:CORNELISON, LESLIE G (RPH)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:G
Last Name:CORNELISON
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 1:96 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1420
Mailing Address - Country:US
Mailing Address - Phone:706-692-7698
Mailing Address - Fax:
Practice Address - Street 1:1449 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4075
Practice Address - Country:US
Practice Address - Phone:706-692-2709
Practice Address - Fax:706-692-8986
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12612183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist