Provider Demographics
NPI:1265021349
Name:KISER, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:KISER
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:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:KS
Mailing Address - Zip Code:67646-0005
Mailing Address - Country:US
Mailing Address - Phone:785-689-8831
Mailing Address - Fax:
Practice Address - Street 1:126 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDICINE LODGE
Practice Address - State:KS
Practice Address - Zip Code:67104-1317
Practice Address - Country:US
Practice Address - Phone:620-886-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist