Provider Demographics
NPI:1144515339
Name:LARIMER, EDWARD A
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:LARIMER
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 1:280 SPRECKELS AVE
Mailing Address - Street 2:T1526
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-6005
Mailing Address - Country:US
Mailing Address - Phone:209-824-9288
Mailing Address - Fax:209-824-9288
Practice Address - Street 1:280 SPRECKELS AVE
Practice Address - Street 2:T1526
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-6005
Practice Address - Country:US
Practice Address - Phone:209-824-9288
Practice Address - Fax:209-824-9288
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist