Provider Demographics
NPI:1376910281
Name:LEE, SO JIN (RPH)
Entity Type:Individual
Prefix:
First Name:SO JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25014 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1118
Mailing Address - Country:US
Mailing Address - Phone:586-359-6517
Mailing Address - Fax:586-359-6523
Practice Address - Street 1:25014 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1118
Practice Address - Country:US
Practice Address - Phone:586-359-6517
Practice Address - Fax:586-359-6523
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist