Provider Demographics
NPI:1326191339
Name:LARSON, SCOTT R
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:LARSON
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 1:1427 AMBER CT
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-2289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634-9054
Practice Address - Country:US
Practice Address - Phone:608-489-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI124921835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric