Provider Demographics
NPI:1265686588
Name:LEE, BONG DE A (RPH)
Entity Type:Individual
Prefix:
First Name:BONG DE
Middle Name:A
Last Name:LEE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105-07 E TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465
Mailing Address - Country:US
Mailing Address - Phone:718-829-2002
Mailing Address - Fax:718-829-2006
Practice Address - Street 1:4105-07 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465
Practice Address - Country:US
Practice Address - Phone:718-829-2002
Practice Address - Fax:718-829-2006
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029568-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00860279Medicaid