Provider Demographics
NPI:1891121448
Name:LEE, GARY ALLEN
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ALLEN
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 1:12189 GREENVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365-1511
Mailing Address - Country:US
Mailing Address - Phone:864-949-3240
Mailing Address - Fax:
Practice Address - Street 1:12189 GREENVILLE HWY
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1511
Practice Address - Country:US
Practice Address - Phone:864-949-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-15
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist