Provider Demographics
NPI:1588390462
Name:LY, TOMMY (PHARMD)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:
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 1:111 PORTOLA VALLEY DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9453
Mailing Address - Country:US
Mailing Address - Phone:304-320-6801
Mailing Address - Fax:
Practice Address - Street 1:533 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166-8526
Practice Address - Country:US
Practice Address - Phone:704-528-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist