Provider Demographics
NPI:1225589690
Name:LA, LONG
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:LA
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 1:606 OAKLAND HILLS DR
Mailing Address - Street 2:APT 301
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-2026
Mailing Address - Country:US
Mailing Address - Phone:240-461-7034
Mailing Address - Fax:
Practice Address - Street 1:4238 W HUNDRED RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1505
Practice Address - Country:US
Practice Address - Phone:804-706-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist