MEDICARE: ELIZABETH SARA LONGO PHARMACY STUDENT

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	183700000X	Pharmacy Technician

General Provider Information

NPI Number	:	1609664481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH SARA LONGO PHARMACY STUDENT

Provider Business Mailing Address
First Line	:	6000 SHEPHERD MOUNTAIN CV UNIT 517
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-4902
Country	:	US
Telephone Number	:	361-737-1905
Fax Number	:

Provider Business Practice Location Address
First Line	:	6000 SHEPHERD MOUNTAIN CV UNIT 517
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-4902
Country	:	US
Telephone Number	:	361-737-1905
Fax Number	:

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

Provider Enumeration Date	:	04/30/2025
Last Update Date	:	04/30/2025

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