Provider Demographics
NPI:1558602581
Name:LEE, HEEJIN
Entity Type:Individual
Prefix:
First Name:HEEJIN
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 1:38451 5TH ST W APT A7
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551
Mailing Address - Country:US
Mailing Address - Phone:319-321-7862
Mailing Address - Fax:
Practice Address - Street 1:9482 CALIFORNIA CITY BLVD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA CITY
Practice Address - State:CA
Practice Address - Zip Code:93505
Practice Address - Country:US
Practice Address - Phone:760-373-5268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68660183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68660Other183500000X