Basic Information
| Provider Information | |||||||||
| NPI: | 1003805474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE, JR | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMACIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 105 W CHOCTAW ST | ||||||||
| Address2: | |||||||||
| City: | DUMAS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716392005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703824007 | ||||||||
| FaxNumber: | 8703824008 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W CHOCTAW ST | ||||||||
| Address2: | |||||||||
| City: | DUMAS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716392005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703824007 | ||||||||
| FaxNumber: | 8703824008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5951 | AR | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 100615407 | 05 | AR | MEDICAID |