MEDICARE: MR. TIM LONG RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	36917	TX

General Provider Information

NPI Number	:	1083210124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIM LONG RPH

Provider Business Mailing Address
First Line	:	213 MILLSTONE LN
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75604-1454
Country	:	US
Telephone Number	:	817-296-4036
Fax Number	:

Provider Business Practice Location Address
First Line	:	4006 ESTES PKWY
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75603-1712
Country	:	US
Telephone Number	:	903-234-2083
Fax Number	:	903-234-2491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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Directions to “ MR. TIM LONG RPH” Practice Location

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