Provider Demographics
NPI:1881691079
Name:LARSEN, TIMOTHY GEORGE (R PH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:GEORGE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5120
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-5120
Mailing Address - Country:US
Mailing Address - Phone:360-458-7110
Mailing Address - Fax:
Practice Address - Street 1:106 1ST ST S
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7700
Practice Address - Country:US
Practice Address - Phone:360-458-8467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist