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General NPI Number Information
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NPI Number | 1174036206
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Entity Type | Individual
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Provider Name | KEITH JOSEPH LARSON JR. PHARMD
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Gender | Male
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Dates
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Enumeration Date | 11/11/2017
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Last Update Date | 11/11/2017
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Provider Practice Location Address
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Address Line | 4 NE PINE ISLAND RD
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City | CAPE CORAL
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State | FL
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Zip | 33909-2560
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Country | US
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Telephone | 239-242-2231
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Fax | 239-242-2235
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Provider Business Mailing Address
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Address Line | 3235 KISMET PKWY W
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City | CAPE CORAL
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State | FL
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Zip | 33993-3303
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Country | US
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Telephone | 239-233-4043
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 51954
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License Number State | FL
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