Provider Demographics
NPI:1831418466
Name:LEE, JAE EUN (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:JAE EUN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-4525
Mailing Address - Country:US
Mailing Address - Phone:323-735-0774
Mailing Address - Fax:
Practice Address - Street 1:4595 HWY 92
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102
Practice Address - Country:US
Practice Address - Phone:770-529-9712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030842183500000X
CARPH59012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist