Provider Demographics
NPI:1083995591
Name:LONG, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10003 FREMONT PIKE
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3330
Mailing Address - Country:US
Mailing Address - Phone:419-872-8247
Mailing Address - Fax:419-472-8358
Practice Address - Street 1:10003 FREMONT PIKE
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-3330
Practice Address - Country:US
Practice Address - Phone:419-872-8247
Practice Address - Fax:419-872-8358
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03223546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist