Provider Demographics
NPI:1003370099
Name:LY, ANNA HANGTHANH
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:HANGTHANH
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HANG
Other - Middle Name:THANH
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7434 MESA COLLEGE DR APT 15
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4924
Mailing Address - Country:US
Mailing Address - Phone:858-888-0768
Mailing Address - Fax:
Practice Address - Street 1:211 W BIRCH ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2348
Practice Address - Country:US
Practice Address - Phone:760-768-3169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist