Provider Demographics
NPI:1477917516
Name:LEE, KENNETH H
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:H
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 1:1968 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3543
Mailing Address - Country:US
Mailing Address - Phone:203-366-8070
Mailing Address - Fax:203-335-2132
Practice Address - Street 1:1968 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3543
Practice Address - Country:US
Practice Address - Phone:203-366-8070
Practice Address - Fax:203-335-2132
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0010851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist