=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295345775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES LEE RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2020
-----------------------------------------------------
Last Update Date | 08/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2655 S 10TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19148-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-467-6050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2467 N WHITTMORE ST
-----------------------------------------------------
City | FURLONG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18925-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-799-6948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP439749
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------