Provider Demographics
NPI:1033498563
Name:LONG, CAROL DIANE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:DIANE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 E FRONTIER ELM DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4948
Mailing Address - Country:US
Mailing Address - Phone:479-236-9065
Mailing Address - Fax:
Practice Address - Street 1:2494 E FRONTIER ELM DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4948
Practice Address - Country:US
Practice Address - Phone:479-236-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist