Provider Demographics
NPI:1619352937
Name:LEIST, ANDREA IRBY
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:IRBY
Last Name:LEIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 OLD MAIN ST UNIT 303
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-3041
Mailing Address - Country:US
Mailing Address - Phone:757-870-5440
Mailing Address - Fax:
Practice Address - Street 1:1214 WESTOVER HILLS BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4434
Practice Address - Country:US
Practice Address - Phone:804-230-6335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214280183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist