Provider Demographics
NPI:1114330867
Name:LOGAN, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WEST G. L. SMITH STREET
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261
Mailing Address - Country:US
Mailing Address - Phone:270-526-5615
Mailing Address - Fax:270-526-7615
Practice Address - Street 1:205 WEST G. L. SMITH STREET
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261
Practice Address - Country:US
Practice Address - Phone:270-526-5615
Practice Address - Fax:270-526-7615
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015437183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist