Provider Demographics
NPI:1083303200
Name:LEE, JUSTIN WOOJIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WOOJIN
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 1:2754 MORAINE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-5006
Mailing Address - Country:US
Mailing Address - Phone:847-834-5181
Mailing Address - Fax:
Practice Address - Street 1:602 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-3405
Practice Address - Country:US
Practice Address - Phone:847-487-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist