Provider Demographics
NPI:1073582946
Name:LONGE DRUGS 1, INC.
Entity Type:Organization
Organization Name:LONGE DRUGS 1, INC.
Other - Org Name:LONGE DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-787-3194
Mailing Address - Street 1:900 E GANSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1700
Mailing Address - Country:US
Mailing Address - Phone:517-787-3194
Mailing Address - Fax:517-787-8005
Practice Address - Street 1:900 E GANSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1700
Practice Address - Country:US
Practice Address - Phone:517-787-3194
Practice Address - Fax:517-787-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010049923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1983740Medicaid
MI1983740Medicaid