Provider Demographics
NPI:1134731631
Name:LOGUE, BRIAN (RPH)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LOGUE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12403 HERMITAGE TRL
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-8626
Mailing Address - Country:US
Mailing Address - Phone:513-319-5323
Mailing Address - Fax:
Practice Address - Street 1:4926 CANE RUN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1149
Practice Address - Country:US
Practice Address - Phone:502-449-5168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028643A183500000X
KY021281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist