Provider Demographics
NPI:1316483340
Name:TRAN, LY
Entity type:Individual
Prefix:
First Name:LY
Middle Name:
Last Name:TRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15804 GARRISON CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-3005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2511 TRIMMIER RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-1908
Practice Address - Country:US
Practice Address - Phone:254-634-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist