Provider Demographics
NPI:1114140779
Name:LARSEN, BRIAN JOHN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOHN
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14266 STONE FLY DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5605
Mailing Address - Country:US
Mailing Address - Phone:801-253-9725
Mailing Address - Fax:
Practice Address - Street 1:10130 S STATE ST
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4118
Practice Address - Country:US
Practice Address - Phone:801-255-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2323145-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist