Provider Demographics
NPI:1306264072
Name:LARSON, JEANANN DAWN (RPH)
Entity type:Individual
Prefix:
First Name:JEANANN
Middle Name:DAWN
Last Name:LARSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1855
Mailing Address - Country:US
Mailing Address - Phone:218-365-7123
Mailing Address - Fax:218-365-7124
Practice Address - Street 1:1500 E SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1855
Practice Address - Country:US
Practice Address - Phone:218-365-7123
Practice Address - Fax:281-365-7124
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist