Provider Demographics
NPI:1639942378
Name:LY, TONY (CPHT)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 PANTALIS CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2636
Mailing Address - Country:US
Mailing Address - Phone:408-649-0938
Mailing Address - Fax:
Practice Address - Street 1:2643 SENTER RD STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1184
Practice Address - Country:US
Practice Address - Phone:408-287-4899
Practice Address - Fax:408-287-4898
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA176842183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician