Provider Demographics
NPI:1841761061
Name:LEE, ESHBAN KYUNGHYUN
Entity Type:Individual
Prefix:
First Name:ESHBAN
Middle Name:KYUNGHYUN
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11140 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6556
Mailing Address - Country:US
Mailing Address - Phone:213-446-9126
Mailing Address - Fax:
Practice Address - Street 1:12815 HEACOCK ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3116
Practice Address - Country:US
Practice Address - Phone:213-446-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist