Healthcare Provider Details

I. General information

NPI: 1336675149
Provider Name (Legal Business Name): WALTER CHONGHWA LEE PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 MOUNT HERMON RD
SCOTTS VALLEY CA
95066-4037
US

IV. Provider business mailing address

257 MOUNT HERMON RD
SCOTTS VALLEY CA
95066-4037
US

V. Phone/Fax

Practice location:
  • Phone: 831-438-5920
  • Fax: 831-438-7800
Mailing address:
  • Phone: 831-438-5920
  • Fax: 831-438-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number38842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: