Basic Information
Provider Information
NPI: 1003139940
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEE
FirstName: GABRIEL
MiddleName: S
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4059 COLLEGE POINT BLVD
Address2:  
City: FLUSHING
State: NY
PostalCode: 113545108
CountryCode: US
TelephoneNumber:  
FaxNumber:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X053778NYY Pharmacy Service ProvidersPharmacist 

ID Information
IDTypeStateIssuerDescription
0320916105NY MEDICAID


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