Healthcare Provider Details

I. General information

NPI: 1568408581
Provider Name (Legal Business Name): LARSEN SERVICE DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 N MAIN ST
WATFORD CITY ND
58854-7122
US

IV. Provider business mailing address

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 TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR163
License Number StateND

VIII. Authorized Official

Name: LARRY LARSEN
Title or Position: PRESIDENT AND OWNER
Credential: RPH
Phone: 701-444-2410