Provider Demographics
NPI:1578138954
Name:LOCKRIDGE, LOGAN DAKOTA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:DAKOTA
Last Name:LOCKRIDGE
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 1:9995 COBB RD
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-9525
Mailing Address - Country:US
Mailing Address - Phone:269-250-0822
Mailing Address - Fax:
Practice Address - Street 1:9995 COBB RD
Practice Address - Street 2:
Practice Address - City:DELTON
Practice Address - State:MI
Practice Address - Zip Code:49046-9525
Practice Address - Country:US
Practice Address - Phone:269-250-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302413371OtherPHARMACY LICENSE