Provider Demographics
NPI:1073395364
Name:LEE, JUSTIN DAVID
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
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 1:22310 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3645
Mailing Address - Country:US
Mailing Address - Phone:718-762-7111
Mailing Address - Fax:
Practice Address - Street 1:22310 UNION TPKE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-3645
Practice Address - Country:US
Practice Address - Phone:718-762-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist