Provider Demographics
NPI:1285479618
Name:LY, BAO VY THI
Entity type:Individual
Prefix:
First Name:BAO VY
Middle Name:THI
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 1:174 RICHMOND DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-8028
Mailing Address - Country:US
Mailing Address - Phone:571-545-1581
Mailing Address - Fax:
Practice Address - Street 1:2233 W US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4761
Practice Address - Country:US
Practice Address - Phone:386-752-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222077183500000X
FLPS67516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist