Provider Demographics
NPI:1609134675
Name:LARSON, MATTHEW THOR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOR
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1422
Mailing Address - Country:US
Mailing Address - Phone:218-546-5144
Mailing Address - Fax:218-546-7238
Practice Address - Street 1:20 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1422
Practice Address - Country:US
Practice Address - Phone:218-546-5144
Practice Address - Fax:218-546-7238
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist