Provider Demographics
NPI:1407242670
Name:LEE, SHIWOO SIMON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHIWOO
Middle Name:SIMON
Last Name:LEE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22129 59TH AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1929
Mailing Address - Country:US
Mailing Address - Phone:845-826-3311
Mailing Address - Fax:
Practice Address - Street 1:393 FRONT ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4026
Practice Address - Country:US
Practice Address - Phone:516-489-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist