Provider Demographics
NPI:1598065005
Name:LY, VIVIAN (PHARMD)
Entity Type:Individual
Prefix:
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 1:20711 BOTHELL EVERETT HWY
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-7139
Mailing Address - Country:US
Mailing Address - Phone:425-486-4473
Mailing Address - Fax:
Practice Address - Street 1:20711 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-7139
Practice Address - Country:US
Practice Address - Phone:425-486-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-31
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS017865183500000X
WAPH00060211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist