Provider Demographics
NPI:1851836605
Name:LY, KAVEN
Entity Type:Individual
Prefix:
First Name:KAVEN
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 COLLEGE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3040 COLLEGE PARK DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8002
Practice Address - Country:US
Practice Address - Phone:936-271-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59380183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist