Healthcare Provider Details

I. General information

NPI: 1861768038
Provider Name (Legal Business Name): LISA RAE OLSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2012
Last Update Date: 03/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-7265
  • Fax: 414-805-7211
Mailing address:
  • Phone: 414-805-7265
  • Fax: 414-805-7211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10634
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: