Provider Demographics
NPI:1790293884
Name:LEE, JESSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSE
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 1:1207 SKIPPACK PIKE
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1246
Mailing Address - Country:US
Mailing Address - Phone:267-640-8197
Mailing Address - Fax:
Practice Address - Street 1:317 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-1403
Practice Address - Country:US
Practice Address - Phone:610-658-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP452126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist