Provider Demographics
NPI:1952813214
Name:LEE, MIN KYEONG
Entity Type:Individual
Prefix:
First Name:MIN KYEONG
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 1:417 S WESTMORELAND AVE UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1563
Mailing Address - Country:US
Mailing Address - Phone:213-769-9665
Mailing Address - Fax:
Practice Address - Street 1:417 S. WESTMORELAND AVE.
Practice Address - Street 2:204
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-9002
Practice Address - Country:US
Practice Address - Phone:213-769-9665
Practice Address - Fax:213-769-9665
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist