Provider Demographics
NPI:1285147314
Name:LY, DUNG PHUONG
Entity type:Individual
Prefix:
First Name:DUNG
Middle Name:PHUONG
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-1021
Mailing Address - Country:US
Mailing Address - Phone:860-635-1507
Mailing Address - Fax:860-635-2016
Practice Address - Street 1:161 BERLIN RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-1021
Practice Address - Country:US
Practice Address - Phone:860-635-1507
Practice Address - Fax:860-635-2016
Is Sole Proprietor?:No
Enumeration Date:2017-11-11
Last Update Date:2017-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist