Provider Demographics
NPI:1679687354
Name:LONG, ALLYSON NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:NICOLE
Last Name:LONG
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 1:50 GALLOWAY CT
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9074
Mailing Address - Country:US
Mailing Address - Phone:317-745-1713
Mailing Address - Fax:
Practice Address - Street 1:50 GALLOWAY CT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9074
Practice Address - Country:US
Practice Address - Phone:317-341-4336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021429A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy