Healthcare Provider Details

I. General information

NPI: 1053288266
Provider Name (Legal Business Name): OLIVIA EYRSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2945 S 6TH ST
SPRINGFIELD IL
62703-4024
US

IV. Provider business mailing address

2249 E BLACK AVE
SPRINGFIELD IL
62702-3132
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-5846
  • Fax:
Mailing address:
  • Phone: 217-788-5846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049324715
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: