Provider Demographics
NPI:1861711442
Name:LY, SHANNA (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19011 GARNET WAY
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4729
Mailing Address - Country:US
Mailing Address - Phone:626-810-0890
Mailing Address - Fax:
Practice Address - Street 1:405 W IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-4818
Practice Address - Country:US
Practice Address - Phone:714-529-2176
Practice Address - Fax:714-529-8834
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-22
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46594183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist