Provider Demographics
NPI:1033295191
Name:LEE, PETER CHOONGSUN
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:CHOONGSUN
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6552 BOLSA AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-2622
Mailing Address - Country:US
Mailing Address - Phone:714-897-2541
Mailing Address - Fax:714-891-2041
Practice Address - Street 1:6552 BOLSA AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2622
Practice Address - Country:US
Practice Address - Phone:714-897-2541
Practice Address - Fax:714-891-2041
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY37314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA373140Medicaid
CA1141130001Medicare ID - Type Unspecified