Provider Demographics
NPI:1649345786
Name:LOGUE, BRIAN WAYNE (RPH)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WAYNE
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 1:32800 FAST AVE
Mailing Address - Street 2:
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755-8894
Mailing Address - Country:US
Mailing Address - Phone:309-359-8706
Mailing Address - Fax:
Practice Address - Street 1:101 N UNIVERSITY ST
Practice Address - Street 2:ISU HEALTH SERVICE PHARMACY
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-2540
Practice Address - Country:US
Practice Address - Phone:309-438-8713
Practice Address - Fax:309-438-7569
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist