Provider Demographics
NPI:1811630593
Name:LEE, JIN AH
Entity Type:Individual
Prefix:
First Name:JIN AH
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 1:324 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5647
Mailing Address - Country:US
Mailing Address - Phone:562-410-7953
Mailing Address - Fax:
Practice Address - Street 1:2720 S HIGHLAND AVE APT 320
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5399
Practice Address - Country:US
Practice Address - Phone:562-410-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0513046753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy