Provider Demographics
NPI:1013458140
Name:OLSEN, BREANNA MARIE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:MARIE
Last Name:OLSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 E THOMPSON BLVD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3537
Mailing Address - Country:US
Mailing Address - Phone:805-648-8985
Mailing Address - Fax:805-253-1991
Practice Address - Street 1:2260 E THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-3537
Practice Address - Country:US
Practice Address - Phone:805-648-8985
Practice Address - Fax:805-253-1991
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist