Provider Demographics
NPI:1194605675
Name:ABBOTT, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 S CLIFFS PKWY
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-7217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 S CLIFFS PKWY
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7217
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0276471835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care