Provider Demographics
NPI:1952662439
Name:LEE, ELLISHA (RPH)
Entity Type:Individual
Prefix:
First Name:ELLISHA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11030 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-8653
Mailing Address - Country:US
Mailing Address - Phone:503-244-3504
Mailing Address - Fax:503-546-3536
Practice Address - Street 1:11030 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-8653
Practice Address - Country:US
Practice Address - Phone:503-244-3504
Practice Address - Fax:503-546-3536
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10166183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist