Provider Demographics
NPI:1255643409
Name:LOGAN, LANCE GRERGORY (PHARMD)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:GRERGORY
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 S CONGRESS AVE APT 248
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-8024
Mailing Address - Country:US
Mailing Address - Phone:512-924-3216
Mailing Address - Fax:
Practice Address - Street 1:5600 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-3108
Practice Address - Country:US
Practice Address - Phone:512-441-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-04
Last Update Date:2010-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist