Provider Demographics
NPI:1144601071
Name:BOOZER, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BOOZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 WESTERN CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-2044
Mailing Address - Country:US
Mailing Address - Phone:817-232-1023
Mailing Address - Fax:817-232-5091
Practice Address - Street 1:4400 WESTERN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-2044
Practice Address - Country:US
Practice Address - Phone:817-232-1023
Practice Address - Fax:817-232-5091
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist