Provider Demographics
NPI:1184354128
Name:LEE, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SE MIDVALE DR APT F103
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-3153
Mailing Address - Country:US
Mailing Address - Phone:775-453-8956
Mailing Address - Fax:
Practice Address - Street 1:3200 SE MIDVALE DR APT F103
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-3153
Practice Address - Country:US
Practice Address - Phone:775-453-8956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician