Provider Demographics
NPI:1063012961
Name:DELONG, KEVIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DELONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 W MOUNT VERNON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-5207
Mailing Address - Country:US
Mailing Address - Phone:417-616-2674
Mailing Address - Fax:
Practice Address - Street 1:3536 W MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-5207
Practice Address - Country:US
Practice Address - Phone:417-616-2674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006019795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist