Provider Demographics
NPI:1770795767
Name:LARSON, LAURELYN JOANN
Entity type:Individual
Prefix:
First Name:LAURELYN
Middle Name:JOANN
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:HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:PARK RIVER
Mailing Address - State:ND
Mailing Address - Zip Code:58270
Mailing Address - Country:US
Mailing Address - Phone:701-284-7676
Mailing Address - Fax:701-284-6129
Practice Address - Street 1:HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:PARK RIVER
Practice Address - State:ND
Practice Address - Zip Code:58270
Practice Address - Country:US
Practice Address - Phone:701-284-7676
Practice Address - Fax:701-284-6129
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist