Provider Demographics
NPI:1083210124
Name:LONG, TIM (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 MILLSTONE LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1454
Mailing Address - Country:US
Mailing Address - Phone:817-296-4036
Mailing Address - Fax:
Practice Address - Street 1:4006 ESTES PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75603-1712
Practice Address - Country:US
Practice Address - Phone:903-234-2083
Practice Address - Fax:903-234-2491
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist