Healthcare Provider Details

I. General information

NPI: 1508205782
Provider Name (Legal Business Name): JACOB OLSON PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 1ST AVE NE
LITTLE FALLS MN
56345-3336
US

IV. Provider business mailing address

1023 1ST AVE NE
LITTLE FALLS MN
56345-3336
US

V. Phone/Fax

Practice location:
  • Phone: 320-632-1639
  • Fax: 320-632-5160
Mailing address:
  • Phone: 320-632-1639
  • Fax: 320-632-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number121224
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: