Provider Demographics
NPI:1003564303
Name:BRIM, LARRY DAVID
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DAVID
Last Name:BRIM
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 1:1151 N LYNN RIGGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3068
Mailing Address - Country:US
Mailing Address - Phone:918-283-3784
Mailing Address - Fax:
Practice Address - Street 1:1151 N LYNN RIGGS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3068
Practice Address - Country:US
Practice Address - Phone:918-283-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100245990AMedicaid