Provider Demographics
NPI:1043468218
Name:LEE, JONG DAE
Entity Type:Individual
Prefix:
First Name:JONG DAE
Middle Name:
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 1:330 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2221
Mailing Address - Country:US
Mailing Address - Phone:201-482-4603
Mailing Address - Fax:201-482-4603
Practice Address - Street 1:904 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3929
Practice Address - Country:US
Practice Address - Phone:718-991-6700
Practice Address - Fax:718-874-1378
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033021-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033021-1OtherNY LICENSE NO.
NY02664726Medicaid
NY027296OtherPHARMACY