Provider Demographics
NPI:1104372911
Name:OLSEN, LAURA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2201
Mailing Address - Country:US
Mailing Address - Phone:618-244-5400
Mailing Address - Fax:618-244-5988
Practice Address - Street 1:3401 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2201
Practice Address - Country:US
Practice Address - Phone:618-244-5400
Practice Address - Fax:618-244-5988
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist