Provider Demographics
NPI:1215538525
Name:LONGO, BRIAN CHARLES
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:LONGO
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 1:654 GREEN FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 RIDGE POINT DR
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-2201
Practice Address - Country:US
Practice Address - Phone:636-375-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009023448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist