Provider Demographics
NPI:1164608840
Name:LEE, SO YEON (RPH)
Entity Type:Individual
Prefix:
First Name:SO YEON
Middle Name:
Last Name:LEE
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 1:65 FAIRVIEW ST
Mailing Address - Street 2:APT 3B
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1037
Mailing Address - Country:US
Mailing Address - Phone:201-944-0989
Mailing Address - Fax:
Practice Address - Street 1:360 ESSEX ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8550
Practice Address - Country:US
Practice Address - Phone:201-498-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-13
Last Update Date:2008-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03037600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist