Provider Demographics
NPI:1477683365
Name:LARSON, ANGELA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 PRAIRIE AVE SW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5517
Mailing Address - Country:US
Mailing Address - Phone:507-332-6714
Mailing Address - Fax:
Practice Address - Street 1:1920 GRANT ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4831
Practice Address - Country:US
Practice Address - Phone:507-334-1555
Practice Address - Fax:507-334-9030
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN106928000Medicaid