Healthcare Provider Details

I. General information

NPI: 1710691803
Provider Name (Legal Business Name): LONG LIEU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 CITY LINE AVE
PHILADELPHIA PA
19131-1435
US

IV. Provider business mailing address

327 W EARLHAM TER
PHILADELPHIA PA
19144-3919
US

V. Phone/Fax

Practice location:
  • Phone: 215-877-2116
  • Fax: 215-877-5064
Mailing address:
  • Phone: 215-605-7303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP457431
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: