Provider Demographics
NPI:1659355717
Name:LEE, BERTRAM (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:BERTRAM
Middle Name:
Last Name:LEE
Suffix:
Gender:M
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:PO BOX 7709
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0709
Mailing Address - Country:US
Mailing Address - Phone:209-478-7452
Mailing Address - Fax:209-320-3507
Practice Address - Street 1:3233 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2751
Practice Address - Country:US
Practice Address - Phone:209-952-1212
Practice Address - Fax:209-952-1232
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH35415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist