Healthcare Provider Details

I. General information

NPI: 1811664014
Provider Name (Legal Business Name): JAKOB LARZ SOUTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 COOPER POINT RD NW STE 103
OLYMPIA WA
98502-4436
US

IV. Provider business mailing address

617 WOODDUCK DR SW
OLYMPIA WA
98502-2672
US

V. Phone/Fax

Practice location:
  • Phone: 360-754-8014
  • Fax:
Mailing address:
  • Phone: 801-833-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH61179182
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: