Healthcare Provider Details

I. General information

NPI: 1427076470
Provider Name (Legal Business Name): LARRON STANLEY DOLENCE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 GOAT SPRINGS ROAD
TAOS NM
87571-1946
US

IV. Provider business mailing address

101 N FORK RD
LANDER WY
82520-9126
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-6990
  • Fax: 575-751-5210
Mailing address:
  • Phone: 307-335-4120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3142
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15832
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: