Provider Demographics
NPI:1063977437
Name:LEE, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5607
Mailing Address - Country:US
Mailing Address - Phone:626-963-1625
Mailing Address - Fax:626-852-9919
Practice Address - Street 1:435 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5607
Practice Address - Country:US
Practice Address - Phone:626-963-1625
Practice Address - Fax:626-852-9919
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist