Healthcare Provider Details

I. General information

NPI: 1598303257
Provider Name (Legal Business Name): KYLE LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900 PARK PLAZA DR STE 150
CERRITOS CA
90703-9329
US

IV. Provider business mailing address

1510 SAN PABLO ST STE 144
LOS ANGELES CA
90033-5394
US

V. Phone/Fax

Practice location:
  • Phone: 562-622-2800
  • Fax:
Mailing address:
  • Phone: 323-442-5992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number81453
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number81453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: