Provider Demographics
NPI:1902251945
Name:VINCENT LY PHARMACY INCORPORATION
Entity Type:Organization
Organization Name:VINCENT LY PHARMACY INCORPORATION
Other - Org Name:986 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-672-9220
Mailing Address - Street 1:701 S ATLANTIC BLVD
Mailing Address - Street 2:SUITE 168
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-3844
Mailing Address - Country:US
Mailing Address - Phone:626-672-9220
Mailing Address - Fax:
Practice Address - Street 1:701 S ATLANTIC BLVD STE 168
Practice Address - Street 2:SUITE 168
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-3866
Practice Address - Country:US
Practice Address - Phone:626-782-7800
Practice Address - Fax:626-782-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY543803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159805OtherPK