Provider Demographics
NPI:1265036750
Name:LEE, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4630
Mailing Address - Country:US
Mailing Address - Phone:781-963-3906
Mailing Address - Fax:
Practice Address - Street 1:171 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4630
Practice Address - Country:US
Practice Address - Phone:781-963-3906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH235259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist