Provider Demographics
NPI:1831224468
Name:OLSON, MARK E (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 1:9430 CHAMPS DE ELYSSES
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-9388
Mailing Address - Country:US
Mailing Address - Phone:707-820-1260
Mailing Address - Fax:
Practice Address - Street 1:218 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3436
Practice Address - Country:US
Practice Address - Phone:707-829-3007
Practice Address - Fax:707-829-5637
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist