Healthcare Provider Details

I. General information

NPI: 1598090995
Provider Name (Legal Business Name): TRAVIS MICHAEL LOGUE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 DAVIS DR
MORRISVILLE NC
27560-8845
US

IV. Provider business mailing address

3601 DAVIS DR
MORRISVILLE NC
27560-8845
US

V. Phone/Fax

Practice location:
  • Phone: 919-468-6880
  • Fax: 919-468-6494
Mailing address:
  • Phone: 919-468-6880
  • Fax: 919-468-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18744
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: