Provider Demographics
NPI:1639173966
Name:LONG, ALAN M
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:M
Last Name:LONG
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 1:124 LEBANON HWY
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37030-2955
Mailing Address - Country:US
Mailing Address - Phone:615-735-1234
Mailing Address - Fax:615-735-1234
Practice Address - Street 1:124 LEBANON HWY
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TN
Practice Address - Zip Code:37030-2955
Practice Address - Country:US
Practice Address - Phone:615-735-1234
Practice Address - Fax:615-735-1234
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2012-08-01
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
TN1888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist