Provider Demographics
NPI:1861953440
Name:LEIBAS, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LEIBAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 PRESERVATION LN
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-19651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist