Provider Demographics
NPI:1710691803
Name:LIEU, LONG
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:LIEU
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 1:327 W EARLHAM TER
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3919
Mailing Address - Country:US
Mailing Address - Phone:215-605-7303
Mailing Address - Fax:
Practice Address - Street 1:5040 CITY LINE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1435
Practice Address - Country:US
Practice Address - Phone:215-877-2116
Practice Address - Fax:215-877-5064
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP457431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist