Provider Demographics
NPI:1821139908
Name:LARSON, KELLI J (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:J
Last Name:LARSON
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 1:1170 ESTHER LN
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4521
Mailing Address - Country:US
Mailing Address - Phone:507-330-3033
Mailing Address - Fax:
Practice Address - Street 1:1601 STATE AVE NW
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5689
Practice Address - Country:US
Practice Address - Phone:507-455-9684
Practice Address - Fax:507-455-1750
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2020-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117666-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist