Provider Demographics
NPI:1457640583
Name:SIMMONS, LARRY (PHARM D)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PHARM D
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 113
Mailing Address - Street 2:
Mailing Address - City:WALLBACK
Mailing Address - State:WV
Mailing Address - Zip Code:25285-0113
Mailing Address - Country:US
Mailing Address - Phone:304-565-3336
Mailing Address - Fax:
Practice Address - Street 1:173 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043
Practice Address - Country:US
Practice Address - Phone:304-587-2224
Practice Address - Fax:304-587-7172
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist