Provider Demographics
NPI:1033875604
Name:LEE, SOYEON KIM
Entity Type:Individual
Prefix:
First Name:SOYEON
Middle Name:KIM
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 TINDALLS CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23436-1130
Mailing Address - Country:US
Mailing Address - Phone:757-333-2156
Mailing Address - Fax:
Practice Address - Street 1:1017 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-0048
Practice Address - Country:US
Practice Address - Phone:757-335-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist