Provider Demographics
NPI:1386492551
Name:LARSON, TRAVIS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2708
Mailing Address - Country:US
Mailing Address - Phone:651-704-0322
Mailing Address - Fax:
Practice Address - Street 1:2196 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2708
Practice Address - Country:US
Practice Address - Phone:651-704-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist