Healthcare Provider Details

I. General information

NPI: 1689894982
Provider Name (Legal Business Name): AGNES H LEE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61MDG-SGSAP 483 NORTH AVIATION BLVD
EL SEGUNDO CA
90245-2808
US

IV. Provider business mailing address

3251 INTERSTATE 45 N STE 190
CONROE TX
77304-2185
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-6662
  • Fax: 310-653-6658
Mailing address:
  • Phone: 310-346-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number68078
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number12141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: