Healthcare Provider Details

I. General information

NPI: 1467781351
Provider Name (Legal Business Name): LARRY CHARLES ELLIOTT CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LARRY C ELLIOTT CPHT

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

4315 DIPLOMACY DR
ANCHORAGE AK
99508-5926
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2107
  • Fax: 907-729-2119
Mailing address:
  • Phone: 907-729-2107
  • Fax: 907-729-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number188
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: