Provider Demographics
NPI:1407836489
Name:BLANK, LARRY STEVEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:STEVEN
Last Name:BLANK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 NW 20TH ST
Mailing Address - Street 2:STE D
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365
Mailing Address - Country:US
Mailing Address - Phone:503-304-7600
Mailing Address - Fax:
Practice Address - Street 1:1 WESTERN OREGON SERVICE UNIT
Practice Address - Street 2:CHEMAWA INDIAN HEALTH CENTER
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1111
Practice Address - Country:US
Practice Address - Phone:503-304-7600
Practice Address - Fax:503-304-7678
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270030Medicaid