Provider Demographics
NPI:1629395538
Name:LONG, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 BEAZELL RD
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-4723
Mailing Address - Country:US
Mailing Address - Phone:724-823-8198
Mailing Address - Fax:
Practice Address - Street 1:446 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONONGAHELA
Practice Address - State:PA
Practice Address - Zip Code:15063-2552
Practice Address - Country:US
Practice Address - Phone:724-258-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-01
Last Update Date:2010-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist