Provider Demographics
NPI:1730760950
Name:ALFARO BRICENO, LEONARDO
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:ALFARO BRICENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10617 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2611
Mailing Address - Country:US
Mailing Address - Phone:317-895-0316
Mailing Address - Fax:
Practice Address - Street 1:10617 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2611
Practice Address - Country:US
Practice Address - Phone:317-895-0316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024446A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist