Provider Demographics
NPI:1750057352
Name:LEE, MOOCHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MOOCHAN
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 1:12401 PRINCESS JEANNE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4639
Mailing Address - Country:US
Mailing Address - Phone:505-382-4904
Mailing Address - Fax:
Practice Address - Street 1:12401 PRINCESS JEANNE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4639
Practice Address - Country:US
Practice Address - Phone:505-382-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist