Provider Demographics
NPI:1336135409
Name:LEE, CHUNGMAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHUNGMAN
Middle Name:
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 1:6725 169TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3305
Mailing Address - Country:US
Mailing Address - Phone:917-693-4211
Mailing Address - Fax:
Practice Address - Street 1:6725 169TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3305
Practice Address - Country:US
Practice Address - Phone:917-693-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043326OtherRPH LICENSE