Provider Demographics
NPI:1861088056
Name:LOGAN, JUSTIN M (PHARM D)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 S MAY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-3275
Mailing Address - Country:US
Mailing Address - Phone:405-682-6191
Mailing Address - Fax:405-685-9613
Practice Address - Street 1:4301 S MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-3275
Practice Address - Country:US
Practice Address - Phone:405-682-6191
Practice Address - Fax:405-685-9613
Is Sole Proprietor?:No
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist