Provider Demographics
NPI:1932483963
Name:SWOVERLAND, LARRY G (RPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:G
Last Name:SWOVERLAND
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 1:1599 QUAIL GLEN CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3462
Mailing Address - Country:US
Mailing Address - Phone:317-523-7311
Mailing Address - Fax:
Practice Address - Street 1:1808 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-1404
Practice Address - Country:US
Practice Address - Phone:317-786-1031
Practice Address - Fax:317-786-1036
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26011939A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26011939AOtherPHARMACY LICENSE