Provider Demographics
NPI:1891361069
Name:LONG, MELODIE ANN (CPHT)
Entity Type:Individual
Prefix:
First Name:MELODIE
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WHITE PINE
Mailing Address - State:TN
Mailing Address - Zip Code:37890-3467
Mailing Address - Country:US
Mailing Address - Phone:865-674-7517
Mailing Address - Fax:865-674-8198
Practice Address - Street 1:1212 STATE ST
Practice Address - Street 2:
Practice Address - City:WHITE PINE
Practice Address - State:TN
Practice Address - Zip Code:37890-3467
Practice Address - Country:US
Practice Address - Phone:865-674-7517
Practice Address - Fax:865-674-8198
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000026120183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician