Provider Demographics
NPI:1306441928
Name:LOGUE, MAUREEN A
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:A
Last Name:LOGUE
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 1:2037 KANSAS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2416
Mailing Address - Country:US
Mailing Address - Phone:605-692-7311
Mailing Address - Fax:
Practice Address - Street 1:790 22ND AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2822
Practice Address - Country:US
Practice Address - Phone:605-692-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist