Provider Demographics
NPI:1558656900
Name:TEBBE, LARRY BERNARD (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:BERNARD
Last Name:TEBBE
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 1:17731 DUCK LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-3511
Mailing Address - Country:US
Mailing Address - Phone:952-934-2203
Mailing Address - Fax:
Practice Address - Street 1:3601 HIGHWAY 100 S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2500
Practice Address - Country:US
Practice Address - Phone:952-926-8967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist