Provider Demographics
NPI:1720388416
Name:LARSON, LARRY A (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N RUBY ST
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3152
Mailing Address - Country:US
Mailing Address - Phone:509-962-5096
Mailing Address - Fax:509-925-6044
Practice Address - Street 1:400 N RUBY ST
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3152
Practice Address - Country:US
Practice Address - Phone:509-962-5096
Practice Address - Fax:509-925-6044
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00014461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist