Provider Demographics
NPI:1790276475
Name:LONG, GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N. PROSPECT, SUITE 56
Mailing Address - Street 2:PO BOX 409
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402
Mailing Address - Country:US
Mailing Address - Phone:419-419-0104
Mailing Address - Fax:
Practice Address - Street 1:1010 N PROSPECT ST STE 56
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1335
Practice Address - Country:US
Practice Address - Phone:419-419-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03226201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist