Healthcare Provider Details

I. General information

NPI: 1114140779
Provider Name (Legal Business Name): BRIAN JOHN LARSEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10130 S STATE ST
SANDY UT
84070-4118
US

IV. Provider business mailing address

14266 STONE FLY DR
BLUFFDALE UT
84065-5605
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-3101
  • Fax:
Mailing address:
  • Phone: 801-253-9725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2323145-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: