Provider Demographics
NPI:1699075325
Name:LEE, MICHAEL GORDON (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GORDON
Last Name:LEE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2309
Mailing Address - Country:US
Mailing Address - Phone:509-684-8481
Mailing Address - Fax:509-684-3572
Practice Address - Street 1:391 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2309
Practice Address - Country:US
Practice Address - Phone:509-684-8481
Practice Address - Fax:509-684-3572
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00016407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist