Provider Demographics
NPI:1073890299
Name:LARSON, DONALD EDWARD JR (RPH)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:EDWARD
Last Name:LARSON
Suffix:JR
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 1:62 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-3040
Mailing Address - Country:US
Mailing Address - Phone:716-662-9146
Mailing Address - Fax:
Practice Address - Street 1:62 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-3040
Practice Address - Country:US
Practice Address - Phone:716-662-9146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042333Medicare UPIN