Provider Demographics
NPI:1114277480
Name:HALLIBURTON, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:HALLIBURTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 E QUINCY AVE
Mailing Address - Street 2:A-309
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8330 E QUINCY AVE
Practice Address - Street 2:A-309
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237
Practice Address - Country:US
Practice Address - Phone:720-272-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0019442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist