Provider Demographics
NPI:1063402089
Name:LEE, JOHN (R PH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2191 NILES ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93305-5007
Mailing Address - Country:US
Mailing Address - Phone:661-327-4248
Mailing Address - Fax:661-327-1025
Practice Address - Street 1:2191 NILES ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-5007
Practice Address - Country:US
Practice Address - Phone:661-327-4248
Practice Address - Fax:661-327-1025
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH22347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1033109319Medicaid
CA0524719OtherNCPDP NUMBER
CA0817670001Medicare ID - Type UnspecifiedPROVIDER NUMBER