Provider Demographics
NPI:1932651882
Name:LEE, JI WON
Entity type:Individual
Prefix:
First Name:JI WON
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 1:5712 255TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2137
Mailing Address - Country:US
Mailing Address - Phone:419-450-5143
Mailing Address - Fax:
Practice Address - Street 1:5712 255TH ST
Practice Address - Street 2:2ND FL.
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2137
Practice Address - Country:US
Practice Address - Phone:419-450-5143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist