Provider Demographics
NPI:1881110716
Name:LARSON, BRAYDON (PHARMD)
Entity type:Individual
Prefix:
First Name:BRAYDON
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:BRAYDON
Other - Middle Name:CURT
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:3487 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3681
Mailing Address - Country:US
Mailing Address - Phone:928-692-1822
Mailing Address - Fax:928-692-1822
Practice Address - Street 1:3487 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3681
Practice Address - Country:US
Practice Address - Phone:928-692-1822
Practice Address - Fax:928-692-6404
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS021662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist