Provider Demographics
NPI:1558606012
Name:LARSON, WARREN (RPH)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1164
Mailing Address - Country:US
Mailing Address - Phone:575-647-8878
Mailing Address - Fax:
Practice Address - Street 1:3041 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1164
Practice Address - Country:US
Practice Address - Phone:575-647-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00005083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist