Provider Demographics
NPI:1992255657
Name:LARSON, DREW
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:LARSON
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 1:0408 SW NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3535
Mailing Address - Country:US
Mailing Address - Phone:541-221-2918
Mailing Address - Fax:
Practice Address - Street 1:4315 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6269
Practice Address - Country:US
Practice Address - Phone:503-771-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0015530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist