Provider Demographics
NPI:1740321348
Name:LARSEN, CORY A (RPH)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:A
Last Name:LARSEN
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 1:5117 W 8620 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-3902
Mailing Address - Country:US
Mailing Address - Phone:801-282-3990
Mailing Address - Fax:
Practice Address - Street 1:6949 HIGH TECH DR
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-3705
Practice Address - Country:US
Practice Address - Phone:801-233-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT316169-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist