Provider Demographics
NPI:1073024402
Name:LY, LAN
Entity Type:Individual
Prefix:
First Name:LAN
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 1:1800 COOKS HILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9162
Mailing Address - Country:US
Mailing Address - Phone:360-827-6616
Mailing Address - Fax:360-827-6657
Practice Address - Street 1:1800 COOKS HILL RD STE B
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9162
Practice Address - Country:US
Practice Address - Phone:360-827-6616
Practice Address - Fax:360-827-6657
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62504183500000X
WAPH61024074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist