Provider Demographics
NPI:1124701636
Name:LEE, SO JEONG
Entity type:Individual
Prefix:
First Name:SO JEONG
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 1:812 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:RARITAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08869-1706
Mailing Address - Country:US
Mailing Address - Phone:610-427-1903
Mailing Address - Fax:
Practice Address - Street 1:1708 PARK AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-5519
Practice Address - Country:US
Practice Address - Phone:908-755-7696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI040355001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist