Provider Demographics
NPI:1952787715
Name:LEE, JONATHAN (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RUSTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4421
Mailing Address - Country:US
Mailing Address - Phone:631-747-6215
Mailing Address - Fax:
Practice Address - Street 1:210 VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-6531
Practice Address - Country:US
Practice Address - Phone:410-394-3711
Practice Address - Fax:410-394-3799
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202215284183500000X
MD24660183500000X
NY060761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist