Provider Demographics
NPI:1093196859
Name:LONGO, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LONGO
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 1:650 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040
Mailing Address - Country:US
Mailing Address - Phone:928-645-5714
Mailing Address - Fax:928-645-1286
Practice Address - Street 1:650 ELM STREET
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-5714
Practice Address - Fax:928-645-1286
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS012588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS012588OtherPHARMACY LICENSE
UT151407-1701OtherPHARMACY LICENSE