Provider Demographics
NPI:1275406209
Name:LY, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
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 1:15300 SE 155TH PL UNIT A307
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8308
Mailing Address - Country:US
Mailing Address - Phone:425-313-5515
Mailing Address - Fax:
Practice Address - Street 1:751 NE BLAKELY DR
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6201
Practice Address - Country:US
Practice Address - Phone:425-313-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61364407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist