Provider Demographics
NPI:1669592507
Name:LONG, SUSAN O (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:O
Last Name:LONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 SOLAR ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-4139
Mailing Address - Country:US
Mailing Address - Phone:276-669-6457
Mailing Address - Fax:
Practice Address - Street 1:13245 LEE HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-5963
Practice Address - Country:US
Practice Address - Phone:276-466-0319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006630183500000X
TN10365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist