Provider Demographics
NPI:1255989190
Name:LARSON, CHRISTI
Entity type:Individual
Prefix:
First Name:CHRISTI
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 S. SUPERSTITION MOUNTAIN DR. SUITE 104, #155
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118
Mailing Address - Country:US
Mailing Address - Phone:888-600-2705
Mailing Address - Fax:
Practice Address - Street 1:6788 S KINGS RANCH RD, SUITE 1
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118
Practice Address - Country:US
Practice Address - Phone:888-600-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist