Provider Demographics
NPI:1295453579
Name:LONG, BRIE EDGERTON (PHARMD)
Entity type:Individual
Prefix:
First Name:BRIE
Middle Name:EDGERTON
Last Name:LONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13202 CLEVELAND ST W
Mailing Address - Street 2:
Mailing Address - City:NAHUNTA
Mailing Address - State:GA
Mailing Address - Zip Code:31553-2875
Mailing Address - Country:US
Mailing Address - Phone:912-462-3784
Mailing Address - Fax:
Practice Address - Street 1:13202 CLEVELAND ST W
Practice Address - Street 2:
Practice Address - City:NAHUNTA
Practice Address - State:GA
Practice Address - Zip Code:31553-2875
Practice Address - Country:US
Practice Address - Phone:912-462-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019522183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist