Provider Demographics
NPI:1124610522
Name:MILLER, LARISSA KAY (PHARMD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:KAY
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 ZUIDER ZEE DR SE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1819
Mailing Address - Country:US
Mailing Address - Phone:605-690-5565
Mailing Address - Fax:
Practice Address - Street 1:1111 HOLTON DR
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2884
Practice Address - Country:US
Practice Address - Phone:712-546-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist