Provider Demographics
NPI:1457760639
Name:LONG, JEFFREY TODD (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TODD
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 1:123 SAINT NAZAIRE RD
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4202
Mailing Address - Country:US
Mailing Address - Phone:337-837-8131
Mailing Address - Fax:337-837-8033
Practice Address - Street 1:123 SAINT NAZAIRE RD
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-4202
Practice Address - Country:US
Practice Address - Phone:337-837-8131
Practice Address - Fax:337-837-8033
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist