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General NPI Number Information
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NPI Number | 1740332782
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Entity Type | Organization
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Legal Business Name | LARRY'S DRIVE IN PHARMACY, INC.
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 313 MADISON AVE
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City | MADISON
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State | WV
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Zip | 25130-1510
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Country | US
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Telephone | 304-369-0209
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Fax | 304-369-1994
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Provider Business Mailing Address
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Address Line | 313 MADISON AVE
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City | MADISON
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State | WV
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Zip | 25130-1510
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Country | US
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Telephone | 304-369-0209
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Fax | 304-369-1994
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Authorized Official
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Title or Position | OWNER
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Name | MR. LARRY E BOWEN
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Credential |
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Telephone | 304-369-0209
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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 | SP0550784
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License Number State | WV
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