Provider Demographics
NPI:1043976533
Name:LY, MAI
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14716 FREEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1610
Mailing Address - Country:US
Mailing Address - Phone:310-706-8326
Mailing Address - Fax:
Practice Address - Street 1:14716 FREEMAN AVE
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1610
Practice Address - Country:US
Practice Address - Phone:310-706-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist