Provider Demographics
NPI:1093052144
Name:LONG, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E PAULDING DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-7190
Mailing Address - Country:US
Mailing Address - Phone:770-505-8988
Mailing Address - Fax:
Practice Address - Street 1:51 E PAULDING DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-7190
Practice Address - Country:US
Practice Address - Phone:770-505-8988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist