MEDICARE: DANIEL 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY39339	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0503121	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750412854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANIEL LEE

Provider Business Mailing Address
First Line	:	4002 30TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-2602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4002 30TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-2602
Country	:	US
Telephone Number	:	619-284-8877
Fax Number	:	619-284-8893

Authorized Official
Title or Position	:	OWNER AND PHARMACIST
Name	:	DANIEL LEE
Credential	:	PHARMD
Telephone Number	:	619-284-8877

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	05/18/2009

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