Healthcare Provider Details

I. General information

NPI: 1073701561
Provider Name (Legal Business Name): LARRY DAVID CARRUTH JR. R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 OAK RIDGE FARM HWY SUITE C
MOORESVILLE NC
28115-7923
US

IV. Provider business mailing address

121 SEABURY DR
MOORESVILLE NC
28117-6045
US

V. Phone/Fax

Practice location:
  • Phone: 704-658-9814
  • Fax: 704-658-0721
Mailing address:
  • Phone: 704-904-5319
  • Fax: 704-658-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14547
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7720
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: