Provider Demographics
NPI:1679617898
Name:LONG, WILLIE EDWARD
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:EDWARD
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:PO BOX 551444
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1444
Mailing Address - Country:US
Mailing Address - Phone:904-766-4700
Mailing Address - Fax:904-764-4900
Practice Address - Street 1:201 W 48TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5230
Practice Address - Country:US
Practice Address - Phone:904-766-4700
Practice Address - Fax:904-764-4900
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0018438183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1077848OtherNCPD NUMBER