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General NPI Number Information
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NPI Number | 1740857184
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Entity Type | Individual
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Provider Name | LARRY PATRICK COSTELLO
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Gender | Male
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Dates
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Enumeration Date | 06/04/2021
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Last Update Date | 06/04/2021
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Provider Practice Location Address
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Address Line | 4668 N SHORE DR
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City | CLEAR LAKE
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State | IA
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Zip | 50428-1275
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Country | US
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Telephone | 641-529-0820
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Fax | 877-814-4512
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Provider Business Mailing Address
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Address Line | 1907 US HIGHWAY 18 E
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City | CLEAR LAKE
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State | IA
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Zip | 50428-2004
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Country | US
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Telephone | 641-357-5271
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Fax | 877-814-4512
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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 | 13166
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License Number State | IA
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