Provider Demographics
NPI:1629051974
Name:LARSON, KENNETH DUANE (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DUANE
Last Name:LARSON
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 1:5671 MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:PESHASTIN
Mailing Address - State:WA
Mailing Address - Zip Code:98847-9765
Mailing Address - Country:US
Mailing Address - Phone:509-548-4903
Mailing Address - Fax:
Practice Address - Street 1:603 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3875
Practice Address - Country:US
Practice Address - Phone:509-962-7329
Practice Address - Fax:509-962-7421
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAML0581404OtherDEA NUMBER