Provider Demographics
NPI:1710234596
Name:LARSSON, MALLORY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LARSSON
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 1:36278 BARTOLDUS LOOP
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8558
Mailing Address - Country:US
Mailing Address - Phone:720-629-1553
Mailing Address - Fax:
Practice Address - Street 1:145 S HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9314
Practice Address - Country:US
Practice Address - Phone:503-861-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist