Provider Demographics
NPI:1124673496
Name:RUPERT, LARRY JAMES
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:JAMES
Last Name:RUPERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NEW FLORENCE
Mailing Address - State:PA
Mailing Address - Zip Code:15944-2513
Mailing Address - Country:US
Mailing Address - Phone:724-464-4341
Mailing Address - Fax:
Practice Address - Street 1:1049 SHOEMAKER ST
Practice Address - Street 2:
Practice Address - City:NANTY GLO
Practice Address - State:PA
Practice Address - Zip Code:15943-1248
Practice Address - Country:US
Practice Address - Phone:814-419-6717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist