Provider Demographics
NPI:1194006197
Name:TAYLOR, LARISSA GEM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:GEM
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13461 NC HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28445-6553
Mailing Address - Country:US
Mailing Address - Phone:910-329-0484
Mailing Address - Fax:910-329-0489
Practice Address - Street 1:13461 NC HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:SURF CITY
Practice Address - State:NC
Practice Address - Zip Code:28445-6553
Practice Address - Country:US
Practice Address - Phone:910-329-0484
Practice Address - Fax:910-329-0489
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist