Provider Demographics
NPI:1508460726
Name:LONGTIN, MICHELLE GRACE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GRACE
Last Name:LONGTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SWEET GUM LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9179
Mailing Address - Country:US
Mailing Address - Phone:602-689-5022
Mailing Address - Fax:
Practice Address - Street 1:2 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28694-7375
Practice Address - Country:US
Practice Address - Phone:336-246-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist