Basic Information
| Provider Information | |||||||||
| NPI: | 1477714061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | NGAN-KIM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35325 DATE PALM DR STE 239 | ||||||||
| Address2: | |||||||||
| City: | CATHEDRAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922347015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609696560 | ||||||||
| FaxNumber: | 7603282230 | ||||||||
| Practice Location | |||||||||
| Address1: | 35325 DATE PALM DR STE 239 | ||||||||
| Address2: | |||||||||
| City: | CATHEDRAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922347015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609696560 | ||||||||
| FaxNumber: | 7603282230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 60534 | CA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 60534 | 01 | CA | STATE LICENSE | OTHER |