Provider Demographics
NPI:1871163493
Name:LY, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:LY
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 1:4010 K ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-5219
Mailing Address - Country:US
Mailing Address - Phone:267-250-1086
Mailing Address - Fax:
Practice Address - Street 1:8200 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2519
Practice Address - Country:US
Practice Address - Phone:215-338-4967
Practice Address - Fax:215-338-2437
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP45701183500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes183500000XPharmacy Service ProvidersPharmacist