Provider Demographics
NPI:1790842839
Name:LARSON, JANE ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ELLEN
Last Name:LARSON
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 1:37422 HEARTHSIDE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-4019
Mailing Address - Country:US
Mailing Address - Phone:651-982-7235
Mailing Address - Fax:651-982-7236
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8013
Practice Address - Country:US
Practice Address - Phone:651-982-7235
Practice Address - Fax:651-982-7236
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1121292183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1121292OtherREGISTERED PHARMACIST