Provider Demographics
NPI:1821674375
Name:LOGAN, SHELIA MARIE
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:MARIE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 FALLING LEAF LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-2270
Mailing Address - Country:US
Mailing Address - Phone:407-766-3612
Mailing Address - Fax:
Practice Address - Street 1:3622 FALLING LEAF LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-2270
Practice Address - Country:US
Practice Address - Phone:407-766-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45188183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1699154161OtherPHARMACY