MEDICARE: JUSTIN LEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	65925	TX

General Provider Information

NPI Number	:	1700481470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN LEE

Provider Business Mailing Address
First Line	:	12803 WEST AVE APT 8110
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-1826
Country	:	US
Telephone Number	:	832-863-8081
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 BROADWAY
Second Line	:
City	:	ALAMO HEIGHTS
State	:	TX
Zip	:	78209-6214
Country	:	US
Telephone Number	:	210-824-1679
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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