Provider Demographics
NPI:1265777221
Name:LONG, WILLIAM J (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:J
Last Name:LONG
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 MECHEM DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-7210
Mailing Address - Country:US
Mailing Address - Phone:575-258-2456
Mailing Address - Fax:
Practice Address - Street 1:1203 MECHEM DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7210
Practice Address - Country:US
Practice Address - Phone:575-258-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00003216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist