Provider Demographics
NPI:1023903176
Name:LONG, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:LONG
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11391 APALACHIAN WAY
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:395 WESTFIELD RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1425
Practice Address - Country:US
Practice Address - Phone:317-776-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029516A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist