MEDICARE: WILLIAM 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
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	113489	MN

General Provider Information

NPI Number	:	1932517844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM LARSON

Provider Business Mailing Address
First Line	:	1221 W LAKE ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3565
Country	:	US
Telephone Number	:	612-270-9652
Fax Number	:	612-821-4799

Provider Business Practice Location Address
First Line	:	1221 W LAKE ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3565
Country	:	US
Telephone Number	:	612-270-9652
Fax Number	:	612-821-4799

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

Provider Enumeration Date	:	07/24/2014
Last Update Date	:	07/24/2014

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