MEDICARE: LIV LARSON PHARMD0

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
1	183500000X	Pharmacist	60860	CA

General Provider Information

NPI Number	:	1265713473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIV LARSON PHARMD0

Provider Business Mailing Address
First Line	:	1933 DAVIS ST STE 244
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-1263
Country	:	US
Telephone Number	:	510-909-0167
Fax Number	:

Provider Business Practice Location Address
First Line	:	11565 SAN PABLO AVE
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-1951
Country	:	US
Telephone Number	:	510-234-9300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	09/01/2011

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