Provider Demographics
NPI:1538478169
Name:SPARKS, LARRY W (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:W
Last Name:SPARKS
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 1:1115 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2802
Mailing Address - Country:US
Mailing Address - Phone:505-875-3700
Mailing Address - Fax:
Practice Address - Street 1:1115 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2802
Practice Address - Country:US
Practice Address - Phone:505-753-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist