Provider Demographics
NPI:1679977789
Name:YUAN, LEO (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LEO
Middle Name:
Last Name:YUAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 SONOMA HWY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-4137
Mailing Address - Country:US
Mailing Address - Phone:707-538-9275
Mailing Address - Fax:
Practice Address - Street 1:4610 SONOMA HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-4137
Practice Address - Country:US
Practice Address - Phone:707-538-9275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA71097OtherCALIFORNIA BOARD OF PHARMACY DHHS