Provider Demographics
NPI:1073194510
Name:OLSON, JAY HARVEY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:HARVEY
Last Name:OLSON
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:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:BATTLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56515-0538
Mailing Address - Country:US
Mailing Address - Phone:218-864-5261
Mailing Address - Fax:218-864-8178
Practice Address - Street 1:113 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:BATTLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56515-4018
Practice Address - Country:US
Practice Address - Phone:218-864-5261
Practice Address - Fax:218-864-8178
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1142313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy