Provider Demographics
NPI:1437523651
Name:OLSON, BRODY (RPH)
Entity Type:Individual
Prefix:
First Name:BRODY
Middle Name:
Last Name:OLSON
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 1:4821 SCHNEIDER DR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53575-2231
Mailing Address - Country:US
Mailing Address - Phone:909-499-7861
Mailing Address - Fax:
Practice Address - Street 1:335 W APPLEWAY AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-9306
Practice Address - Country:US
Practice Address - Phone:208-765-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-26
Last Update Date:2015-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7406183500000X
WI18082-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist