Provider Demographics
NPI:1083971428
Name:LOGAN, RENEE (P D)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:P D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W DE QUEEN AVE
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832
Mailing Address - Country:US
Mailing Address - Phone:870-584-3555
Mailing Address - Fax:870-642-7259
Practice Address - Street 1:205 W DE QUEEN AVE.
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832
Practice Address - Country:US
Practice Address - Phone:870-584-3555
Practice Address - Fax:870-642-7259
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6741100001Medicare NSC