Provider Demographics
NPI:1831794999
Name:HENKEN, LARRY ANTHONY (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ANTHONY
Last Name:HENKEN
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 1:113 RUTH DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2444
Mailing Address - Country:US
Mailing Address - Phone:618-444-9377
Mailing Address - Fax:314-921-1036
Practice Address - Street 1:1520 MASCOUTAH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3631
Practice Address - Country:US
Practice Address - Phone:618-235-2204
Practice Address - Fax:314-921-1036
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016003862183500000X
IL051038689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist