Provider Demographics
NPI:1598391286
Name:LEE, MICHELLE TAEJUNG
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:TAEJUNG
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 1:3 WILWADE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1120
Mailing Address - Country:US
Mailing Address - Phone:516-557-3248
Mailing Address - Fax:
Practice Address - Street 1:333 CROSSWAYS PARK DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2066
Practice Address - Country:US
Practice Address - Phone:631-321-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218320183500000X
NY067651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist