Provider Demographics
NPI:1568408581
Name:LARSEN SERVICE DRUG INC
Entity Type:Organization
Organization Name:LARSEN SERVICE DRUG INC
Other - Org Name:LARSEN SERVICE DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-444-2410
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-0550
Mailing Address - Country:US
Mailing Address - Phone:701-444-2410
Mailing Address - Fax:701-444-2921
Practice Address - Street 1:244 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7122
Practice Address - Country:US
Practice Address - Phone:701-444-2410
Practice Address - Fax:701-444-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NDPHAR1633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND020166Medicaid
2071165OtherPK
ND020166Medicaid