Healthcare Provider Details

I. General information

NPI: 1699691790
Provider Name (Legal Business Name): BRANDON MICHAEL LONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 TYHEE AVE
AMERICAN FALLS ID
83211-1224
US

IV. Provider business mailing address

524 TYHEE AVE
AMERICAN FALLS ID
83211-1224
US

V. Phone/Fax

Practice location:
  • Phone: 208-226-2411
  • Fax:
Mailing address:
  • Phone: 208-220-4622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9881115
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: