Healthcare Provider Details

I. General information

NPI: 1306432372
Provider Name (Legal Business Name): CHRISTY LONGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 A1A S
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

1920 A1A S
ST AUGUSTINE FL
32080-6508
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-2010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS43726
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: