Provider Demographics
NPI:1336558071
Name:LEE, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
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 1:5233 US HIGHWAY 98 N
Mailing Address - Street 2:APT# 173
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-0533
Mailing Address - Country:US
Mailing Address - Phone:814-248-9572
Mailing Address - Fax:
Practice Address - Street 1:410 OLD POLK CITY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-2314
Practice Address - Country:US
Practice Address - Phone:863-815-3373
Practice Address - Fax:863-815-5303
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52036183500000X
PARP448949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist