Provider Demographics
NPI:1447633870
Name:WONDERFUL, LEAH KRISTINE (PHARMD, BCGP)
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:KRISTINE
Last Name:WONDERFUL
Suffix:
Gender:F
Credentials:PHARMD, BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 ROSELAWN AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5955
Mailing Address - Country:US
Mailing Address - Phone:612-434-1313
Mailing Address - Fax:
Practice Address - Street 1:228 STRAWBRIDGE DR
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-4600
Practice Address - Country:US
Practice Address - Phone:612-434-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist