Provider Demographics
NPI:1447320734
Name:LARENDA INC
Entity type:Organization
Organization Name:LARENDA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT , PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:MADISON
Authorized Official - Last Name:MOZINGO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-683-5436
Mailing Address - Street 1:156 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-1218
Mailing Address - Country:US
Mailing Address - Phone:903-683-5436
Mailing Address - Fax:903-683-2689
Practice Address - Street 1:156 W 5TH ST
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-1218
Practice Address - Country:US
Practice Address - Phone:903-683-5436
Practice Address - Fax:903-683-2689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14417333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143691Medicaid