Provider Demographics
NPI:1356828768
Name:LOGAN, SALLY GAIL (RPH)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:GAIL
Last Name:LOGAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3494
Mailing Address - Country:US
Mailing Address - Phone:800-548-9809
Mailing Address - Fax:866-622-0247
Practice Address - Street 1:5725 NE 138TH AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230
Practice Address - Country:US
Practice Address - Phone:800-548-9809
Practice Address - Fax:866-622-0247
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0006891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0006891OtherOREGON STATE PHARMACIST LICENSE