Provider Demographics
NPI:1093952095
Name:FANGSRUD, LARRY WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:FANGSRUD
Suffix:
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 1:6962 1ST ST W
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-5702
Mailing Address - Country:US
Mailing Address - Phone:406-265-2031
Mailing Address - Fax:
Practice Address - Street 1:3180 HWY 2 W
Practice Address - Street 2:KMART PHARMACY
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501
Practice Address - Country:US
Practice Address - Phone:406-265-1854
Practice Address - Fax:406-265-4647
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist