Provider Demographics
NPI:1063653582
Name:LY, WILSON OAI (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:OAI
Last Name:LY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 CASTRO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2827
Mailing Address - Country:US
Mailing Address - Phone:626-675-1984
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:ADULT MEDICINE CLINIC 1M-3
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-8432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA596621835P0018X, 261QA0600X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No282N00000XHospitalsGeneral Acute Care Hospital