Healthcare Provider Details

I. General information

NPI: 1295795474
Provider Name (Legal Business Name): TOM ALAN LARSON PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 HARVARD ST SE 7-159 WDH
MINNEAPOLIS MN
55455-0353
US

IV. Provider business mailing address

16800 DUCK LAKE TRL
EDEN PRAIRIE MN
55346-3647
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-5025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number113168-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: