Provider Demographics
NPI:1689017626
Name:OLSEN, JEREMY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2921
Mailing Address - Country:US
Mailing Address - Phone:435-259-8971
Mailing Address - Fax:
Practice Address - Street 1:425 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2921
Practice Address - Country:US
Practice Address - Phone:435-259-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6100016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist