Provider Demographics
NPI:1578118345
Name:LEE, RANDY DALE JR (PHARM D)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DALE
Last Name:LEE
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 MALLORY PL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4510
Mailing Address - Country:US
Mailing Address - Phone:619-942-1248
Mailing Address - Fax:
Practice Address - Street 1:5349 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7505
Practice Address - Country:US
Practice Address - Phone:318-397-8152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist