Provider Demographics
NPI:1467493106
Name:OLSEN, GARY LEE (BS PHARM)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:OLSEN
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ROBIN LN SW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-9887
Mailing Address - Country:US
Mailing Address - Phone:218-444-9487
Mailing Address - Fax:
Practice Address - Street 1:1401 PAUL BUNYAN DR NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4155
Practice Address - Country:US
Practice Address - Phone:218-751-8178
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117972-3183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist