Healthcare Provider Details

I. General information

NPI: 1417560368
Provider Name (Legal Business Name): DEVAN ANDREW LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 N STATE ST
OREM UT
84057-3807
US

IV. Provider business mailing address

763 N STATE ST
OREM UT
84057-3807
US

V. Phone/Fax

Practice location:
  • Phone: 801-734-1624
  • Fax: 801-734-1627
Mailing address:
  • Phone: 801-734-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9523307-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: