Provider Demographics
NPI:1336501212
Name:LY, DON QUOC
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:QUOC
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12782 LORNA ST
Mailing Address - Street 2:APT. A
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-5068
Mailing Address - Country:US
Mailing Address - Phone:714-829-8145
Mailing Address - Fax:
Practice Address - Street 1:8008 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4229
Practice Address - Country:US
Practice Address - Phone:562-904-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 54178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist