Provider Demographics
NPI:1174155170
Name:LONG, PHILLIP BRANDON (RPH)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRANDON
Last Name:LONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1570
Mailing Address - Country:US
Mailing Address - Phone:623-806-2959
Mailing Address - Fax:
Practice Address - Street 1:2040 E MARIPOSA RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205
Practice Address - Country:US
Practice Address - Phone:209-465-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist