MEDICARE: DR. ROGER GEORGE LONG PHARM.D.

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	RI15676	NJ
2	183500000X	Pharmacist	PS 41785	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PU 6363	OTHER	FL	FL BOARD OF PHARMACY, CONSULTANT LICENSE

General Provider Information

NPI Number	:	1366445124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER GEORGE LONG PHARM.D.

Provider Business Mailing Address
First Line	:	1230 SW 50TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-7051
Country	:	US
Telephone Number	:	239-471-0299
Fax Number	:

Provider Business Practice Location Address
First Line	:	1631 DEL PRADO BLVD S
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-6739
Country	:	US
Telephone Number	:	239-574-9183
Fax Number	:	239-574-9483

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	01/16/2013

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