Provider Demographics
NPI:1407183429
Name:LY, KIM TUYET (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:TUYET
Last Name:LY
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 S GREAT SOUTHWEST PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:972-602-8155
Mailing Address - Fax:
Practice Address - Street 1:4103 S GREAT SOUTHWEST PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:972-602-8156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist