Provider Demographics
NPI:1285222778
Name:LONG, BRENDAN VISITHS (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:VISITHS
Last Name:LONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-2359
Mailing Address - Country:US
Mailing Address - Phone:413-664-8712
Mailing Address - Fax:
Practice Address - Street 1:45 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-2359
Practice Address - Country:US
Practice Address - Phone:413-664-8712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH239909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist