Provider Demographics
NPI:1457707036
Name:LARSEN, LAUREL J (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3572 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4318
Mailing Address - Country:US
Mailing Address - Phone:773-583-9858
Mailing Address - Fax:773-267-2313
Practice Address - Street 1:3572 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4318
Practice Address - Country:US
Practice Address - Phone:773-583-9858
Practice Address - Fax:773-267-2313
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist