Healthcare Provider Details

I. General information

NPI: 1124580543
Provider Name (Legal Business Name): LARINA BOURNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5589
US

IV. Provider business mailing address

234 E 149TH ST FL 5C RM 168
BRONX NY
10451-5589
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-6536
  • Fax:
Mailing address:
  • Phone: 718-579-6536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberI067485
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberCI067485
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: