Provider Demographics
NPI:1639479025
Name:LY, DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 ALHAMBRA BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5212
Mailing Address - Country:US
Mailing Address - Phone:916-456-3421
Mailing Address - Fax:916-456-3406
Practice Address - Street 1:1025 ALHAMBRA BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5212
Practice Address - Country:US
Practice Address - Phone:916-456-3421
Practice Address - Fax:916-456-3406
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist