Provider Demographics
NPI:1154851525
Name:OESTMANN, LOGAN MITCHELL
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:MITCHELL
Last Name:OESTMANN
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 1:100 MAGNOLIA ST UNIT 1212
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-2214
Mailing Address - Country:US
Mailing Address - Phone:352-727-1484
Mailing Address - Fax:
Practice Address - Street 1:4495 ROOSEVELT BLVD STE E-1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3375
Practice Address - Country:US
Practice Address - Phone:904-388-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL56276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist