Provider Demographics
NPI:1417000969
Name:CROLL, LARRY D (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:CROLL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 380
Mailing Address - Street 2:GILA CROSSING HEALTH CENTER PHARMACY
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-0380
Mailing Address - Country:US
Mailing Address - Phone:602-528-1422
Mailing Address - Fax:602-528-3363
Practice Address - Street 1:51ST AVE AND BELTLINE RD
Practice Address - Street 2:GILA CROSSING HEALTH CENTER PHARMACY POB 380
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-0380
Practice Address - Country:US
Practice Address - Phone:602-528-1422
Practice Address - Fax:602-528-3363
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11714183500000X
SD3812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD3812OtherPHARMACY LICENSE
AZ11714OtherPHARMACY LICENSE