Provider Demographics
NPI:1275803843
Name:LEE, MARK THOMAS (DPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:LEE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MOSS BRANCH CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7580
Mailing Address - Country:US
Mailing Address - Phone:731-668-2295
Mailing Address - Fax:
Practice Address - Street 1:3107 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3113
Practice Address - Country:US
Practice Address - Phone:731-686-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist