Provider Demographics
NPI:1508204827
Name:LOGUERCIO, BREANNA
Entity Type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:
Last Name:LOGUERCIO
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 1:1421 N RENAISSANCE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-7018
Mailing Address - Country:US
Mailing Address - Phone:505-344-9129
Mailing Address - Fax:
Practice Address - Street 1:1421 N RENAISSANCE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-7018
Practice Address - Country:US
Practice Address - Phone:505-344-9129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist