Provider Demographics
NPI:1811537764
Name:BECKER, LARRY EUGENE
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:EUGENE
Last Name:BECKER
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 1:12199 455TH AVE
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-7216
Mailing Address - Country:US
Mailing Address - Phone:605-698-4124
Mailing Address - Fax:
Practice Address - Street 1:115 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-1412
Practice Address - Country:US
Practice Address - Phone:605-698-2222
Practice Address - Fax:605-698-2226
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist