MEDICARE: DR. JEFFREY COLEMAN LARSEN PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	8185	NM

General Provider Information

NPI Number	:	1720458318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY COLEMAN LARSEN PHARMD

Provider Business Mailing Address
First Line	:	1131 UNIVERSITY BLVD NE
Second Line	:	SUITE G
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-1728
Country	:	US
Telephone Number	:	505-272-2341
Fax Number	:

Provider Business Practice Location Address
First Line	:	1131 UNIVERSITY BLVD NE
Second Line	:	SUITE G
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-1728
Country	:	US
Telephone Number	:	505-272-2341
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2015
Last Update Date	:	08/12/2016

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