Provider Demographics
NPI:1194032490
Name:LARSON, JESSICA M (RPH)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020
Mailing Address - Country:US
Mailing Address - Phone:207-625-4427
Mailing Address - Fax:207-625-3880
Practice Address - Street 1:151 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CORNISH
Practice Address - State:ME
Practice Address - Zip Code:04020-3103
Practice Address - Country:US
Practice Address - Phone:207-625-8494
Practice Address - Fax:207-625-3880
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist