Provider Demographics
NPI:1003554817
Name:LONG, RUSTY WADE
Entity Type:Individual
Prefix:
First Name:RUSTY
Middle Name:WADE
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 S GEORGE NIGH EXPY
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-6025
Mailing Address - Country:US
Mailing Address - Phone:918-423-8060
Mailing Address - Fax:
Practice Address - Street 1:432 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-6025
Practice Address - Country:US
Practice Address - Phone:918-423-8060
Practice Address - Fax:918-423-8409
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist