Provider Demographics
NPI:1003116153
Name:SELKOW, LARRY (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:SELKOW
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 1:55104 OAK TREE
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-5617
Mailing Address - Country:US
Mailing Address - Phone:760-702-0694
Mailing Address - Fax:
Practice Address - Street 1:55104 OAK TREE
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-5617
Practice Address - Country:US
Practice Address - Phone:760-702-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist