Provider Demographics
NPI:1881297661
Name:LY, KHUONG QUOC (RPH)
Entity type:Individual
Prefix:
First Name:KHUONG
Middle Name:QUOC
Last Name:LY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 ANNALEA COVE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4176
Mailing Address - Country:US
Mailing Address - Phone:214-315-6321
Mailing Address - Fax:
Practice Address - Street 1:1496 FM 407
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-2125
Practice Address - Country:US
Practice Address - Phone:972-317-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty