Provider Demographics
NPI:1750666996
Name:LONGWORTH, LYNN D (RPH)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:D
Last Name:LONGWORTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3263 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5702
Mailing Address - Country:US
Mailing Address - Phone:208-319-0612
Mailing Address - Fax:208-319-0627
Practice Address - Street 1:3263 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5702
Practice Address - Country:US
Practice Address - Phone:208-319-0612
Practice Address - Fax:208-319-0627
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist