Healthcare Provider Details

I. General information

NPI: 1730930165
Provider Name (Legal Business Name): THEODORE JOSHUA OLBRICHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1 VIBURNUM CENTER SUITE B
VIBURNUM MO
65566
US

IV. Provider business mailing address

485 COUNTRYSIDE DR
ROLLA MO
65401-4722
US

V. Phone/Fax

Practice location:
  • Phone: 573-244-3785
  • Fax: 573-244-3700
Mailing address:
  • Phone: 765-491-3220
  • Fax: 573-244-3700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2003004928
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: