Provider Demographics
NPI:1053916742
Name:LEE, KEVIN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 S CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:GILMAN
Mailing Address - State:IL
Mailing Address - Zip Code:60938-1518
Mailing Address - Country:US
Mailing Address - Phone:815-265-4730
Mailing Address - Fax:815-265-4740
Practice Address - Street 1:720 S CRESCENT ST
Practice Address - Street 2:
Practice Address - City:GILMAN
Practice Address - State:IL
Practice Address - Zip Code:60938-1518
Practice Address - Country:US
Practice Address - Phone:815-265-4730
Practice Address - Fax:815-265-4740
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-298571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist