Provider Demographics
NPI:1376148973
Name:NELSON, LOGAN ROBERT (PHARMD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:ROBERT
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 EAGLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-3201
Mailing Address - Country:US
Mailing Address - Phone:651-436-4732
Mailing Address - Fax:
Practice Address - Street 1:2150 EAGLE CREEK LN
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-3201
Practice Address - Country:US
Practice Address - Phone:651-436-4732
Practice Address - Fax:651-436-4738
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist