Provider Demographics
NPI:1679165005
Name:LY, QUYEN THE (PHARMD)
Entity Type:Individual
Prefix:
First Name:QUYEN
Middle Name:THE
Last Name:LY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 MATT LEONARD DR SW
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-5064
Mailing Address - Country:US
Mailing Address - Phone:404-786-7830
Mailing Address - Fax:
Practice Address - Street 1:9248 PARKWAY E
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35206-1509
Practice Address - Country:US
Practice Address - Phone:205-833-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA052644407Medicaid