Provider Demographics
NPI:1053077081
Name:LE, AUDREY (RPH)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N BROADWAY # B101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-4700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 N BROADWAY # B101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-4700
Practice Address - Country:US
Practice Address - Phone:323-275-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist