=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447320734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARENDA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 06/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 W 5TH ST
-----------------------------------------------------
City | RUSK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75785-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-683-5436
-----------------------------------------------------
Fax | 903-683-2689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 156 W 5TH ST
-----------------------------------------------------
City | RUSK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75785-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-683-5436
-----------------------------------------------------
Fax | 903-683-2689
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT , PHARMACIST IN CHARGE
-----------------------------------------------------
Name | LARRY MADISON MOZINGO
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 903-683-5436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 14417
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------