Provider Demographics
NPI:1992081871
Name:LONG, RYAN PORTER (PHARM D)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:PORTER
Last Name:LONG
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 WEST HWY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-8811
Mailing Address - Country:US
Mailing Address - Phone:435-789-7936
Mailing Address - Fax:
Practice Address - Street 1:1316 WEST HWY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-8811
Practice Address - Country:US
Practice Address - Phone:435-789-7936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7344956-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist