Provider Demographics
NPI:1386705440
Name:LONG'S LAKESHORE DISCOUNT PHARMACY LLC
Entity type:Organization
Organization Name:LONG'S LAKESHORE DISCOUNT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:256-825-0063
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-0134
Mailing Address - Country:US
Mailing Address - Phone:256-825-0063
Mailing Address - Fax:256-825-5584
Practice Address - Street 1:221 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-1923
Practice Address - Country:US
Practice Address - Phone:256-825-0063
Practice Address - Fax:256-825-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1104923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002455Medicaid
0123721OtherNCPDP PROVIDER IDENTIFICATION NUMBER