Provider Demographics
NPI:1770851727
Name:MILLER, LARRY DAVID (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DAVID
Last Name:MILLER
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 1:1744 SUBURBAN AVE
Mailing Address - Street 2:T-0068
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-6699
Mailing Address - Country:US
Mailing Address - Phone:651-778-0105
Mailing Address - Fax:
Practice Address - Street 1:1744 SUBURBAN AVE
Practice Address - Street 2:0068
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-6619
Practice Address - Country:US
Practice Address - Phone:651-778-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist