Provider Demographics
NPI:1437789641
Name:LEE, EUGENE
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 EL RIO ST APT C
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5166
Mailing Address - Country:US
Mailing Address - Phone:631-278-0606
Mailing Address - Fax:
Practice Address - Street 1:1730 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4405
Practice Address - Country:US
Practice Address - Phone:707-459-0554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist