Provider Demographics
NPI:1063796720
Name:LONG, PAULINE KENNARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:PAULINE
Middle Name:KENNARD
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 1:1815 9TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35020-3421
Mailing Address - Country:US
Mailing Address - Phone:205-425-1757
Mailing Address - Fax:205-425-8103
Practice Address - Street 1:1815 9TH AVE N
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-3421
Practice Address - Country:US
Practice Address - Phone:205-425-1757
Practice Address - Fax:205-425-8103
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist