=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730889791
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PENG LY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2023
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 FRUITRIDGE RD
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95822-3114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-457-5733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 LOMA MAR CT
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95828-1314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-588-7378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 87638
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------