Provider Demographics
NPI:1891273173
Name:LEE, DEREK DONGSUK (PHARMD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:DONGSUK
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 1:7716 S TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1559
Mailing Address - Country:US
Mailing Address - Phone:617-894-9984
Mailing Address - Fax:
Practice Address - Street 1:705 E MCDOWELL RD
Practice Address - Street 2:PHARMACY
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2519
Practice Address - Country:US
Practice Address - Phone:602-258-4865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist