Provider Demographics
NPI:1144805508
Name:LY, BAO G (RPH)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:G
Last Name:LY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 MIRAGE CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7611
Mailing Address - Country:US
Mailing Address - Phone:707-934-5378
Mailing Address - Fax:
Practice Address - Street 1:2336 MIRAGE CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7611
Practice Address - Country:US
Practice Address - Phone:707-934-5378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455496183500000X
CARPH84130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist