Provider Demographics
NPI:1497178461
Name:PHAM, LONG (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LONG
Middle Name:
Last Name:PHAM
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 1:2171 ONEAL LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-3206
Mailing Address - Country:US
Mailing Address - Phone:225-751-6364
Mailing Address - Fax:225-751-9821
Practice Address - Street 1:2171 ONEAL LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3206
Practice Address - Country:US
Practice Address - Phone:225-751-6364
Practice Address - Fax:225-751-9821
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19084183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1269999Medicaid