Provider Demographics
NPI:1457672248
Name:LEE, JAE SUNG
Entity Type:Individual
Prefix:MR
First Name:JAE
Middle Name:SUNG
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12491 VALLEY VIEW ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-2032
Mailing Address - Country:US
Mailing Address - Phone:714-894-9230
Mailing Address - Fax:
Practice Address - Street 1:12491 VALLEY VIEW ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92845-2032
Practice Address - Country:US
Practice Address - Phone:714-894-9230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH51483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist