Provider Demographics
NPI:1558724245
Name:LEE, KEUNHYUNG
Entity Type:Individual
Prefix:
First Name:KEUNHYUNG
Middle Name:
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 1:226 FOUNTAIN ST
Mailing Address - Street 2:APT 607
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1953
Mailing Address - Country:US
Mailing Address - Phone:860-885-4933
Mailing Address - Fax:
Practice Address - Street 1:767 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2534
Practice Address - Country:US
Practice Address - Phone:203-691-5405
Practice Address - Fax:203-691-5107
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0013028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist