Provider Demographics
NPI:1376044222
Name:LY, THANH
Entity type:Individual
Prefix:
First Name:THANH
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 1:10500 SW 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-8162
Mailing Address - Country:US
Mailing Address - Phone:503-780-8201
Mailing Address - Fax:
Practice Address - Street 1:12607 SE MILL PLAIN BLCD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:866-279-1758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0016478183500000X
WA61319269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist