Provider Demographics
NPI:1619244365
Name:MCDANIEL, LARRY A
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:A
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 WESTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2029
Mailing Address - Country:US
Mailing Address - Phone:812-853-8482
Mailing Address - Fax:
Practice Address - Street 1:7769 HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630
Practice Address - Country:US
Practice Address - Phone:812-853-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013146A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist