Provider Demographics
NPI:1487260170
Name:LARSON, AMBER (PHARMD)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LARSON
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 1:3111 GUNDERSEN DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8447
Mailing Address - Country:US
Mailing Address - Phone:608-775-8699
Mailing Address - Fax:608-775-8695
Practice Address - Street 1:3111 GUNDERSEN DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8447
Practice Address - Country:US
Practice Address - Phone:608-775-8699
Practice Address - Fax:608-775-8695
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19575-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist