Provider Demographics
NPI:1063565034
Name:LARSON, ROSS ALAN (PHARM D)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:ALAN
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4272 119TH ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5677
Mailing Address - Country:US
Mailing Address - Phone:715-861-3158
Mailing Address - Fax:
Practice Address - Street 1:849 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3362
Practice Address - Country:US
Practice Address - Phone:715-726-8540
Practice Address - Fax:715-720-0264
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13956-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist