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NPI Code Detail

MEDICARE: BRIAN WAYNE LOGUE RPH.

MEDICARE: BRIAN WAYNE LOGUE RPH.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacistIL

General Provider Information

NPI Number : 1649345786
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIAN WAYNE LOGUE RPH.
Provider Business Mailing Address
First Line : 32800 FAST AVE
Second Line :
City : MACKINAW
State : IL
Zip : 61755-8894
Country : US
Telephone Number : 309-359-8706
Fax Number :
Provider Business Practice Location Address
First Line : 101 N UNIVERSITY ST
Second Line : ISU HEALTH SERVICE PHARMACY
City : NORMAL
State : IL
Zip : 61790-2540
Country : US
Telephone Number : 309-438-8713
Fax Number : 309-438-7569
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/22/2006
Last Update Date : 07/08/2007

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Directions to “ BRIAN WAYNE LOGUE RPH.” Practice Location

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