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NPI Code Detail

MEDICARE: JACQUELINE LARSON

MEDICARE: JACQUELINE LARSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist6272SD
2183500000XPharmacist122227MN

General Provider Information

NPI Number : 1073993622
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELINE LARSON
Provider Business Mailing Address
First Line : 10420 MARYLAND AVE N
Second Line :
City : BROOKLYN PARK
State : MN
Zip : 55445-3278
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 10501 FLORIDA AVE S
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55438-2553
Country : US
Telephone Number : 952-854-1190
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2015
Last Update Date : 06/12/2020

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