Provider Demographics
NPI:1093060568
Name:NEW, LARRY JACK JR
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JACK
Last Name:NEW
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:JACK
Other - Last Name:NEW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2596 FOREST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41527-8404
Mailing Address - Country:US
Mailing Address - Phone:606-237-7539
Mailing Address - Fax:
Practice Address - Street 1:210 LOGAN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3608
Practice Address - Country:US
Practice Address - Phone:304-235-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist