Provider Demographics
NPI:1851008858
Name:KRASS, LOGAN SAMUEL
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:SAMUEL
Last Name:KRASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-8623
Mailing Address - Country:US
Mailing Address - Phone:802-626-4366
Mailing Address - Fax:802-626-4370
Practice Address - Street 1:412 BROAD ST
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851-8623
Practice Address - Country:US
Practice Address - Phone:802-626-4366
Practice Address - Fax:802-626-4370
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist