MEDICARE: MR. DOUGLAS LONG R.P.H

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	1174	TN

General Provider Information

NPI Number	:	1306872379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS LONG R.P.H

Provider Business Mailing Address
First Line	:	105A BROYLES ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2517
Country	:	US
Telephone Number	:	423-282-1178
Fax Number	:	423-282-0462

Provider Business Practice Location Address
First Line	:	105A BROYLES ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2517
Country	:	US
Telephone Number	:	423-282-1178
Fax Number	:	423-282-0462

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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