Healthcare Provider Details

I. General information

NPI: 1275149791
Provider Name (Legal Business Name): JONATHAN JAMES LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 W STATE HIGHWAY 22
RATCLIFF AR
72951-9000
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-279-7709
  • Fax:
Mailing address:
  • Phone: 479-279-7709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD09557
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: