Healthcare Provider Details

I. General information

NPI: 1760685614
Provider Name (Legal Business Name): LARRY C. LARSEN R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 NORTH MAIN STREET
WATFORD CITY ND
58854-0550
US

IV. Provider business mailing address

244 NORTH MAIN STREET PO BOX 550
WATFORD CITY ND
58854-0550
US

V. Phone/Fax

Practice location:
  • Phone: 701-444-2410
  • Fax: 701-444-2921
Mailing address:
  • Phone: 701-444-2410
  • Fax: 701-444-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4086
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: