Provider Demographics
NPI:1619476009
Name:BOSSAER, LARISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:BOSSAER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 EMERALD CHASE CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4969
Mailing Address - Country:US
Mailing Address - Phone:843-696-0157
Mailing Address - Fax:
Practice Address - Street 1:208 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7343
Practice Address - Country:US
Practice Address - Phone:423-989-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist