Provider Demographics
NPI:1952683732
Name:LONG, SUSAN S
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BEAM RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-3405
Mailing Address - Country:US
Mailing Address - Phone:812-378-4701
Mailing Address - Fax:
Practice Address - Street 1:2400 BEAM RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3405
Practice Address - Country:US
Practice Address - Phone:812-378-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6527183500000X
IN26017484A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist