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NPI Code Detail

MEDICARE: LARSON PHCY INC

MEDICARE: LARSON PHCY INC
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
1333600000XPharmacy
23336C0003XCommunity/Retail Pharmacy2607595MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12407698OTHEROTHER ID NUMBER-COMMERCIAL NUMBER
22407698OTHEROTHER ID NUMBER

General Provider Information

NPI Number : 1952520264
Entity Type Code : Organization
Provider Name (Legal Business Name) : LARSON PHCY INC
Provider Business Mailing Address
First Line : 6544 PENN AVE S
Second Line :
City : RICHFIELD
State : MN
Zip : 55423-1143
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6544 PENN AVE S
Second Line :
City : RICHFIELD
State : MN
Zip : 55423-1143
Country : US
Telephone Number : 612-866-8405
Fax Number :
Authorized Official
Title or Position : PRES
Name : MARK LARSON
Credential :
Telephone Number : 612-866-8405
Provider Enumeration Date : 04/25/2007
Last Update Date : 09/12/2007

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