Provider Demographics
NPI:1780275057
Name:LONG, SUSAN MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
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 1:7054 HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-9495
Mailing Address - Country:US
Mailing Address - Phone:701-308-0734
Mailing Address - Fax:
Practice Address - Street 1:407 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4143
Practice Address - Country:US
Practice Address - Phone:704-683-5282
Practice Address - Fax:701-683-5218
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist