Provider Demographics
NPI:1023187101
Name:PEDERSON, LARRY WILLIAM (RPH, CPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WILLIAM
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:RPH, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-0558
Mailing Address - Fax:386-328-9443
Practice Address - Street 1:1302 RIVER ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5042
Practice Address - Country:US
Practice Address - Phone:386-328-0558
Practice Address - Fax:386-328-9443
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0015494183500000X
FLPU0002781183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist