Provider Demographics
NPI:1932791449
Name:LONG, MARIE KATHLEEN (CPHT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:KATHLEEN
Last Name:LONG
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 CIVIC DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1988
Mailing Address - Country:US
Mailing Address - Phone:209-915-5394
Mailing Address - Fax:
Practice Address - Street 1:380 CIVIC DR
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-1988
Practice Address - Country:US
Practice Address - Phone:209-915-5394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132437183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician