=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073475810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LONG PHAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2025
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 HIGHWAY US-79 S
-----------------------------------------------------
City | HAUGHTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-949-8476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 WARHAWK WAY APT 20
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-3162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-654-4047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PMP.036194-PST
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------