Provider Demographics
NPI:1700466190
Name:LY, JESSICA QUEPHUONG (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:QUEPHUONG
Last Name:LY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:112 LA CASA VIA STE 100
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3016
Mailing Address - Country:US
Mailing Address - Phone:925-939-6312
Mailing Address - Fax:925-939-0101
Practice Address - Street 1:112 LA CASA VIA STE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3016
Practice Address - Country:US
Practice Address - Phone:925-939-6312
Practice Address - Fax:925-939-0101
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-10
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CARPH73312183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist