Provider Demographics
NPI:1538390323
Name:LEAKE, MICHAEL SCOTT (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:LEAKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1829
Mailing Address - Country:US
Mailing Address - Phone:802-442-5602
Mailing Address - Fax:802-442-3931
Practice Address - Street 1:205 NORTH ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1829
Practice Address - Country:US
Practice Address - Phone:802-442-5602
Practice Address - Fax:802-442-3931
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033-0003559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist