Healthcare Provider Details

I. General information

NPI: 1033737150
Provider Name (Legal Business Name): LOGAN M KISSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W MAIN ST
OTTAWA OH
45875-1725
US

IV. Provider business mailing address

10000 PARK PLAZA DR APT 301
PITTSBURGH PA
15229-3125
US

V. Phone/Fax

Practice location:
  • Phone: 419-523-6030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number03439762
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: