Provider Demographics
NPI:1407346091
Name:OLSON, JEFFREY TODD
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TODD
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 1:118-120 NORTH FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273
Mailing Address - Country:US
Mailing Address - Phone:515-462-2282
Mailing Address - Fax:515-462-2296
Practice Address - Street 1:118-120 NORTH FIRST AVE
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273
Practice Address - Country:US
Practice Address - Phone:515-462-2282
Practice Address - Fax:515-462-2296
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1604657OtherNABP
IA0031955Medicaid
IA1952490500OtherPHARMACY NPI