Provider Demographics
NPI:1053704015
Name:LEUCK, JOHN JR (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LEUCK
Suffix:JR
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 1:4414 MARSEILLES ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-4236
Mailing Address - Country:US
Mailing Address - Phone:619-997-8354
Mailing Address - Fax:
Practice Address - Street 1:3345 SPORTS ARENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4567
Practice Address - Country:US
Practice Address - Phone:619-222-5818
Practice Address - Fax:619-222-5879
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist