Provider Demographics
NPI:1831483957
Name:WADE, NANCY LOGAN (BS PHARM)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:LOGAN
Last Name:WADE
Suffix:
Gender:F
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6661
Mailing Address - Country:US
Mailing Address - Phone:636-379-1918
Mailing Address - Fax:636-379-1918
Practice Address - Street 1:2300 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-6661
Practice Address - Country:US
Practice Address - Phone:636-379-1918
Practice Address - Fax:636-379-1918
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist