Provider Demographics
NPI:1851969406
Name:LOGAN, BRENDA JEANNE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEANNE
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 1:1025 ASHMUN ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-2707
Mailing Address - Country:US
Mailing Address - Phone:906-632-6874
Mailing Address - Fax:906-632-1849
Practice Address - Street 1:1025 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2707
Practice Address - Country:US
Practice Address - Phone:906-632-6874
Practice Address - Fax:906-632-1849
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303010235183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician