Provider Demographics
NPI:1750538542
Name:LEE, KEVIN Y
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:Y
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 1:208 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1310
Mailing Address - Country:US
Mailing Address - Phone:917-648-1242
Mailing Address - Fax:
Practice Address - Street 1:617 W 181ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4937
Practice Address - Country:US
Practice Address - Phone:212-923-6912
Practice Address - Fax:212-923-6934
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY046379OtherNY STATE PHARMACIST LICENSE NUMBERS