Provider Demographics
NPI:1750460978
Name:LEE, FRED EARNEST (REG PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:EARNEST
Last Name:LEE
Suffix:
Gender:M
Credentials:REG PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 TIMUCUA TRAIL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277
Mailing Address - Country:US
Mailing Address - Phone:904-743-8942
Mailing Address - Fax:
Practice Address - Street 1:1531 MONUMENT ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-998-8999
Practice Address - Fax:904-998-0099
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL9914PS009914183500000X
GAGA8290RPHO8290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist