Healthcare Provider Details

I. General information

NPI: 1255643409
Provider Name (Legal Business Name): LANCE GRERGORY LOGAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2010
Last Update Date: 07/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 S 1ST ST
AUSTIN TX
78745-3108
US

IV. Provider business mailing address

3809 S CONGRESS AVE APT 248
AUSTIN TX
78704-8024
US

V. Phone/Fax

Practice location:
  • Phone: 512-441-4747
  • Fax:
Mailing address:
  • Phone: 512-924-3216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47303
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: