Healthcare Provider Details

I. General information

NPI: 1215930540
Provider Name (Legal Business Name): RICHARD N LOGAN JR. PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S MAIN ST
CHARLESTON MO
63834-1644
US

IV. Provider business mailing address

406 S MAIN ST
CHARLESTON MO
63834-1644
US

V. Phone/Fax

Practice location:
  • Phone: 575-368-3330
  • Fax: 573-683-3308
Mailing address:
  • Phone: 575-368-3330
  • Fax: 573-683-3308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29249
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: