Healthcare Provider Details

I. General information

NPI: 1255972956
Provider Name (Legal Business Name): NICHELLE M LOGAN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 KING OF PRUSSIA RD
RADNOR PA
19087-5227
US

IV. Provider business mailing address

250 KING OF PRUSSIA RD
RADNOR PA
19087-5227
US

V. Phone/Fax

Practice location:
  • Phone: 267-624-5417
  • Fax:
Mailing address:
  • Phone: 614-403-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRP453983
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: