Provider Demographics
NPI:1043500424
Name:LONG, BRAD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
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 1:1211 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3528
Mailing Address - Country:US
Mailing Address - Phone:419-289-3717
Mailing Address - Fax:419-289-8898
Practice Address - Street 1:1211 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3528
Practice Address - Country:US
Practice Address - Phone:419-289-3717
Practice Address - Fax:419-289-8898
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03319811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist