1407996770 NPI number — DR. CRAIG DAVID LARSON RPH, PHARMD

Table of content: DR. CRAIG DAVID LARSON RPH, PHARMD (NPI 1407996770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407996770 NPI number — DR. CRAIG DAVID LARSON RPH, PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
CRAIG
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RPH, PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407996770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1929 S CEDAR AVE
Provider Second Line Business Mailing Address:
STERLING DRUG
Provider Business Mailing Address City Name:
OWATONNA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55060-4302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-451-0240
Provider Business Mailing Address Fax Number:
507-451-5134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 W FOUNTAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBETA LEA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55060-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-301-3000
Provider Business Practice Location Address Fax Number:
507-451-5134
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  117665-8 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060858100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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