Active NPI
Theodore QM Ly
- Pharmacist
- San Luis Obispo, CA
National Provider Identifier
1053980839
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 84269
- Practice address
- 1251 Johnson Ave
San Luis Obispo, CA 93401-3306 - Phone
- (805) 545-0655
- NPI assigned
- Jun 24, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 84269 | CA | Primary |
Addresses
Primary practice location
1251 Johnson Ave
San Luis Obispo, CA 93401-3306
Mailing address
1633 W Southgate Ave
Fullerton, CA 92833-3850
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 84269 | CA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1624492800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1624492800000",
"number": "1053980839",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1633 W SOUTHGATE AVE",
"city": "FULLERTON",
"state": "CA",
"postal_code": "928333850"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1251 JOHNSON AVE",
"city": "SAN LUIS OBISPO",
"state": "CA",
"postal_code": "934013306",
"telephone_number": "805-545-0655"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LY",
"first_name": "THEODORE",
"middle_name": "QM",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-06-24",
"last_updated": "2021-06-24",
"certification_date": "2021-06-24",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "CA",
"license": "84269",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Luis Obispo, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.