Provider Demographics
NPI:1205403458
Name:LONG, LAURA M
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
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 1:302 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49057-1008
Mailing Address - Country:US
Mailing Address - Phone:269-621-3654
Mailing Address - Fax:269-621-3534
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057-1008
Practice Address - Country:US
Practice Address - Phone:269-621-3654
Practice Address - Fax:269-621-3534
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303007454183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5303007454OtherPHARMACY TECHNICIAN LICENSE