Healthcare Provider Details

I. General information

NPI: 1336059310
Provider Name (Legal Business Name): NICO LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3117 US HIGHWAY 9
OLD BRIDGE NJ
08857-2690
US

IV. Provider business mailing address

3 BEARSLEY DR
EAST BRUNSWICK NJ
08816-2041
US

V. Phone/Fax

Practice location:
  • Phone: 732-679-3555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04518800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: