Provider Demographics
NPI:1437471943
Name:LOCKETT, LARISSA FAYE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:FAYE
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13009 NE HIGHWAY 99
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-2741
Mailing Address - Country:US
Mailing Address - Phone:360-574-0914
Mailing Address - Fax:360-573-8931
Practice Address - Street 1:13009 NE HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2741
Practice Address - Country:US
Practice Address - Phone:360-574-0914
Practice Address - Fax:360-573-8931
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00070006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist