Provider Demographics
NPI:1760847172
Name:LOGOTHETIS, MICHAEL PETER (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PETER
Last Name:LOGOTHETIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:PETER
Other - Last Name:LOGOTHETIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:604 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CARLSTADT
Mailing Address - State:NJ
Mailing Address - Zip Code:07072-1849
Mailing Address - Country:US
Mailing Address - Phone:201-460-1319
Mailing Address - Fax:201-460-1319
Practice Address - Street 1:604 MADISON ST
Practice Address - Street 2:
Practice Address - City:CARLSTADT
Practice Address - State:NJ
Practice Address - Zip Code:07072-1849
Practice Address - Country:US
Practice Address - Phone:201-460-1319
Practice Address - Fax:201-460-1319
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01892500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist