Provider Demographics
NPI:1033409669
Name:KELLEY, LOGAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:KELLEY
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 1:107 ASHFORD DR APT 2723
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2310 CLAY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-3123
Practice Address - Country:US
Practice Address - Phone:601-661-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-16
Last Update Date:2011-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS010895183500000X
LA018795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist