Provider Demographics
NPI:1144505280
Name:LEE, JOHN HENRY JR (R PH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:HENRY
Last Name:LEE
Suffix:JR
Gender:M
Credentials:R PH
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:HENRY
Other - Last Name:LEE
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:R PH
Mailing Address - Street 1:7433 S CHAPPEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3619
Mailing Address - Country:US
Mailing Address - Phone:773-493-1589
Mailing Address - Fax:773-493-0019
Practice Address - Street 1:7433 S CHAPPEL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3619
Practice Address - Country:US
Practice Address - Phone:773-493-1589
Practice Address - Fax:773-493-0019
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029754183500000X, 1835P1200X, 261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051029754OtherPHARMACIST LICENSE NUMBER
ILL00046848145OtherDIVERS LICENSE