Provider Demographics
NPI:1043797533
Name:LONG, MARVIN EUGENE II
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:EUGENE
Last Name:LONG
Suffix:II
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 1:1813 DANBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4600
Practice Address - Country:US
Practice Address - Phone:704-847-8508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist