Provider Demographics
NPI:1861037525
Name:LEE, LISA SUNGSOOK
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SUNGSOOK
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 1:102 S SANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-3798
Mailing Address - Country:US
Mailing Address - Phone:951-487-9185
Mailing Address - Fax:951-654-5978
Practice Address - Street 1:102 S SANDERSON AVE
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582-3798
Practice Address - Country:US
Practice Address - Phone:951-487-9185
Practice Address - Fax:951-654-5978
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist