Provider Demographics
NPI:1336690148
Name:LEE, ROGER (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
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 1:8723 ALDEN DR
Mailing Address - Street 2:S244
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-0955
Mailing Address - Country:US
Mailing Address - Phone:310-423-5775
Mailing Address - Fax:
Practice Address - Street 1:8723 ALDEN DR
Practice Address - Street 2:S244
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-0955
Practice Address - Country:US
Practice Address - Phone:310-423-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist