Provider Demographics
NPI:1295164440
Name:BLOODWORTH, LEOTIS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LEOTIS
Middle Name:
Last Name:BLOODWORTH
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 1:10632 CLAUDE FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1509
Mailing Address - Country:US
Mailing Address - Phone:704-287-1974
Mailing Address - Fax:
Practice Address - Street 1:10632 CLAUDE FREEMAN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1509
Practice Address - Country:US
Practice Address - Phone:704-287-1974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist