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General NPI Number Information
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NPI Number | 1184304347
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Entity Type | Individual
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Provider Name | KYUNG JAE LEE PHARMD
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Gender | Male
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Dates
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Enumeration Date | 07/24/2023
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Last Update Date | 05/30/2024
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Provider Practice Location Address
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Address Line | 4850 N LINDER RD
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City | MERIDIAN
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State | ID
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Zip | 83646-6159
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Country | US
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Telephone | 208-319-0047
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Fax |
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Provider Business Mailing Address
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Address Line | 4850 N LINDER RD
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City | MERIDIAN
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State | ID
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Zip | 83646-6159
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Country | US
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Telephone | 208-319-0047
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | P10652
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PH238571
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PH61526496
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License Number State | WA
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