Provider Demographics
NPI:1083110357
Name:LONG, LEVI RAYMOND (PHARMD)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:RAYMOND
Last Name:LONG
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 1:105 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-3323
Mailing Address - Country:US
Mailing Address - Phone:515-232-1653
Mailing Address - Fax:
Practice Address - Street 1:105 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-3323
Practice Address - Country:US
Practice Address - Phone:515-232-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist