Provider Demographics
NPI:1003280082
Name:LARSON, DAVID VERNON (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:VERNON
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31236 N TRAIL DUST DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4139
Mailing Address - Country:US
Mailing Address - Phone:480-459-1739
Mailing Address - Fax:480-457-1089
Practice Address - Street 1:31236 N TRAIL DUST DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4139
Practice Address - Country:US
Practice Address - Phone:480-459-1739
Practice Address - Fax:480-457-1089
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist