Healthcare Provider Details

I. General information

NPI: 1194032490
Provider Name (Legal Business Name): JESSICA M LARSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MAPLE ST
CORNISH ME
04020-3103
US

IV. Provider business mailing address

151 MAPLE ST
CORNISH ME
04020
US

V. Phone/Fax

Practice location:
  • Phone: 207-625-8494
  • Fax: 207-625-3880
Mailing address:
  • Phone: 207-625-4427
  • Fax: 207-625-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR4052
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: