Provider Demographics
NPI:1811376684
Name:LEE, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
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 1:674 LAS POSAS RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-5716
Mailing Address - Country:US
Mailing Address - Phone:805-445-1431
Mailing Address - Fax:
Practice Address - Street 1:674 LAS POSAS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-5716
Practice Address - Country:US
Practice Address - Phone:805-445-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist