Provider Demographics
NPI:1154794824
Name:NAM, LENA
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:NAM
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 1:15069 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-5260
Mailing Address - Country:US
Mailing Address - Phone:951-833-4330
Mailing Address - Fax:951-674-0194
Practice Address - Street 1:29985 CANYON HILLS RD
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2576
Practice Address - Country:US
Practice Address - Phone:951-244-6001
Practice Address - Fax:951-244-2116
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist