Provider Demographics
NPI:1023523008
Name:LARSEN, CORY JAMES (PHARMD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:JAMES
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 E GARRYANNA DR
Mailing Address - Street 2:
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-2208
Mailing Address - Country:US
Mailing Address - Phone:408-393-8645
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-474-6588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist