Provider Demographics
NPI:1659665842
Name:LONG, TABETHA M (RPH)
Entity Type:Individual
Prefix:
First Name:TABETHA
Middle Name:M
Last Name:LONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TABETHA
Other - Middle Name:M
Other - Last Name:TALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:3400 GREEN MOUNT CROSSING DR
Mailing Address - Street 2:T-1539
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7277
Mailing Address - Country:US
Mailing Address - Phone:618-628-3334
Mailing Address - Fax:
Practice Address - Street 1:3400 GREEN MOUNT CROSSING DR
Practice Address - Street 2:T-1539
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7277
Practice Address - Country:US
Practice Address - Phone:618-628-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2011-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290201183500000X
MO2011011784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist