Provider Demographics
NPI:1447353511
Name:LESLIE J WELLS
Entity type:Organization
Organization Name:LESLIE J WELLS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-768-2161
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:FRENCHBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40322-0109
Mailing Address - Country:US
Mailing Address - Phone:606-768-2161
Mailing Address - Fax:606-768-2877
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRENCHBURG
Practice Address - State:KY
Practice Address - Zip Code:40322-8318
Practice Address - Country:US
Practice Address - Phone:606-768-2161
Practice Address - Fax:606-768-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP061373336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54030531Medicaid
2028678OtherPK
KY54030531Medicaid