Basic Information
| Provider Information | |||||||||
| NPI: | 1003139940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4059 COLLEGE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113545108 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4059 COLLEGE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113545108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188889338 | ||||||||
| FaxNumber: | 7188889299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2010 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 053778 | NY | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 03209161 | 05 | NY | MEDICAID |