Provider Demographics
NPI:1740857184
Name:COSTELLO, LARRY PATRICK
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:PATRICK
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 US HIGHWAY 18 E
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-2004
Mailing Address - Country:US
Mailing Address - Phone:641-357-5271
Mailing Address - Fax:877-814-4512
Practice Address - Street 1:4668 N SHORE DR
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-1275
Practice Address - Country:US
Practice Address - Phone:641-529-0820
Practice Address - Fax:877-814-4512
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13166183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist