Provider Demographics
NPI:1023460656
Name:LEE, JAESUNG (RPH)
Entity type:Individual
Prefix:
First Name:JAESUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9274
Mailing Address - Country:US
Mailing Address - Phone:989-362-3439
Mailing Address - Fax:
Practice Address - Street 1:211 W LAKE ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9274
Practice Address - Country:US
Practice Address - Phone:989-362-3439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040620183500000X
OH03135399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist