Healthcare Provider Details

I. General information

NPI: 1043500424
Provider Name (Legal Business Name): BRAD LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 CLAREMONT AVE
ASHLAND OH
44805-3528
US

IV. Provider business mailing address

1211 CLAREMONT AVE
ASHLAND OH
44805-3528
US

V. Phone/Fax

Practice location:
  • Phone: 419-289-3717
  • Fax: 419-289-8898
Mailing address:
  • Phone: 419-289-3717
  • Fax: 419-289-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03319811
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: