Healthcare Provider Details

I. General information

NPI: 1053980839
Provider Name (Legal Business Name): THEODORE QM LY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 JOHNSON AVE
SAN LUIS OBISPO CA
93401-3306
US

IV. Provider business mailing address

1633 W SOUTHGATE AVE
FULLERTON CA
92833-3850
US

V. Phone/Fax

Practice location:
  • Phone: 805-545-0655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number84269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: