Provider Demographics
NPI:1306097290
Name:OLESEN, EVERT LEROY (PHARM D)
Entity type:Individual
Prefix:
First Name:EVERT
Middle Name:LEROY
Last Name:OLESEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1934
Mailing Address - Country:US
Mailing Address - Phone:507-537-9139
Mailing Address - Fax:507-537-9119
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-537-9139
Practice Address - Fax:507-537-9119
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist