Provider Demographics
NPI:1689337610
Name:LEE, KYEONGMIN
Entity Type:Individual
Prefix:
First Name:KYEONGMIN
Middle Name:
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 1:430 S GRAMERCY PL APT 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4903
Mailing Address - Country:US
Mailing Address - Phone:213-215-8855
Mailing Address - Fax:
Practice Address - Street 1:124 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4106
Practice Address - Country:US
Practice Address - Phone:323-464-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist