Provider Demographics
NPI:1255306288
Name:MYERS, LARRY LEE (RP)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:MYERS
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73581 Q RD
Mailing Address - Street 2:PO BOX 804
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-4139
Mailing Address - Country:US
Mailing Address - Phone:308-995-5414
Mailing Address - Fax:308-995-2051
Practice Address - Street 1:414 EAST AVE
Practice Address - Street 2:
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-2215
Practice Address - Country:US
Practice Address - Phone:308-995-5414
Practice Address - Fax:308-995-2051
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47072558800Medicaid
NE2802773OtherNCPDP #
NE47072558800Medicaid