Provider Demographics
NPI:1013625219
Name:LY, DIANE C
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 OSAGE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-1570
Practice Address - Country:US
Practice Address - Phone:781-599-4482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH241226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist