Provider Demographics
NPI:1194524728
Name:MOUA, PATRICIA LY
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LY
Last Name:MOUA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 87TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-1364
Mailing Address - Country:US
Mailing Address - Phone:612-327-6957
Mailing Address - Fax:
Practice Address - Street 1:4175 VINEWOOD LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2624
Practice Address - Country:US
Practice Address - Phone:763-553-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist