Provider Demographics
NPI:1871808659
Name:BOHMFALK, LARRY WAYNE (RPH)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:BOHMFALK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19565 IH 35 S.
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052
Mailing Address - Country:US
Mailing Address - Phone:830-772-4360
Mailing Address - Fax:830-709-2092
Practice Address - Street 1:19565 INTERSTATE HIGHWAY 35 SOUTH
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052
Practice Address - Country:US
Practice Address - Phone:830-772-4360
Practice Address - Fax:830-709-2092
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28310183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist