Provider Demographics
NPI:1093541559
Name:LY, RICHARD (PHARMD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 S ELM PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3220
Mailing Address - Country:US
Mailing Address - Phone:918-455-8308
Mailing Address - Fax:
Practice Address - Street 1:4704 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-3220
Practice Address - Country:US
Practice Address - Phone:918-455-8308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist