Healthcare Provider Details

I. General information

NPI: 1073475810
Provider Name (Legal Business Name): LONG PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 HIGHWAY US-79 S
HAUGHTON LA
71037
US

IV. Provider business mailing address

801 WARHAWK WAY APT 20
MONROE LA
71203-3162
US

V. Phone/Fax

Practice location:
  • Phone: 318-949-8476
  • Fax:
Mailing address:
  • Phone: 318-654-4047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPMP.036194-PST
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: