Provider Demographics
NPI:1093897399
Name:LONG, MIKE THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:THOMAS
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 1:575 19TH AVENUE DR NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-1279
Mailing Address - Country:US
Mailing Address - Phone:828-327-8058
Mailing Address - Fax:
Practice Address - Street 1:126 N CENTER ST
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-6215
Practice Address - Country:US
Practice Address - Phone:828-322-7717
Practice Address - Fax:828-322-3803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist