Provider Demographics
NPI:1639773351
Name:LEE, JENNA MARY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARY
Last Name:LEE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:GLENMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12077-3310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11140 WESTERN TPKE
Practice Address - Street 2:
Practice Address - City:ESPERANCE
Practice Address - State:NY
Practice Address - Zip Code:12066-3010
Practice Address - Country:US
Practice Address - Phone:518-875-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist