1093841041 NPI number — SANG J LEE

Table of content: (NPI 1093841041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093841041 NPI number — SANG J LEE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANG J LEE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LEES DISCOUNT DRUG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093841041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2732 W OLYMPIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90006-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-382-6391
Provider Business Mailing Address Fax Number:
213-387-7475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2732 W OLYMPIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90006-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-382-6391
Provider Business Practice Location Address Fax Number:
213-387-7475
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
SANG
Authorized Official Middle Name:
JU
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
213-382-6391

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY21567 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA215670 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com