Provider Demographics
NPI:1245530559
Name:LY, HENRY (PHARM D)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15143 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-6363
Mailing Address - Country:US
Mailing Address - Phone:206-351-1130
Mailing Address - Fax:
Practice Address - Street 1:16750 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9539
Practice Address - Country:US
Practice Address - Phone:623-546-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS015061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist