Healthcare Provider Details

I. General information

NPI: 1083684906
Provider Name (Legal Business Name): OLSON'S MODERN DRUG CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 WASHINGTON ST
MONTPELIER ID
83254-1422
US

IV. Provider business mailing address

762 WASHINGTON ST
MONTPELIER ID
83254-1422
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-0536
  • Fax: 208-847-1578
Mailing address:
  • Phone: 208-847-0536
  • Fax: 208-847-1578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number476CP
License Number StateID

VIII. Authorized Official

Name: MR. HAROLD A OLSON
Title or Position: OWNER-PHARMACIST
Credential:
Phone: 208-847-0536