Provider Demographics
NPI:1316459324
Name:LY, TIN LANG QUOC (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TIN LANG
Middle Name:QUOC
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 1:700 E OCEAN BLVD UNIT 3102
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5041
Mailing Address - Country:US
Mailing Address - Phone:714-724-1996
Mailing Address - Fax:
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5259
Practice Address - Country:US
Practice Address - Phone:714-543-4025
Practice Address - Fax:714-543-5467
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist