Provider Demographics
NPI:1376824573
Name:LY, VIVIAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAN PEDRO RD
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-2528
Mailing Address - Country:US
Mailing Address - Phone:650-756-3412
Mailing Address - Fax:650-756-2074
Practice Address - Street 1:222 W 39TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4364
Practice Address - Country:US
Practice Address - Phone:650-372-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH56013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH56013OtherCALIFORNIA BOARD OF PHARMACY