Provider Demographics
NPI:1023588159
Name:OLESON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:OLESON
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 1:1100 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ADAIR
Mailing Address - State:IA
Mailing Address - Zip Code:50002-1015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1905 E 7TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1916
Practice Address - Country:US
Practice Address - Phone:712-243-9223
Practice Address - Fax:712-243-9225
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-02
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA184733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy