Provider Demographics
NPI:1558639005
Name:CHRISTENSEN, LARRY LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:CHRISTENSEN
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 1:225 E ASH AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6157
Mailing Address - Country:US
Mailing Address - Phone:217-872-1758
Mailing Address - Fax:217-872-1797
Practice Address - Street 1:225 ASH AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-872-1758
Practice Address - Fax:217-872-1797
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-025897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist