Provider Demographics
NPI:1730930165
Name:OLBRICHT, THEODORE JOSHUA
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOSHUA
Last Name:OLBRICHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4722
Mailing Address - Country:US
Mailing Address - Phone:765-491-3220
Mailing Address - Fax:573-244-3700
Practice Address - Street 1:#1 VIBURNUM CENTER SUITE B
Practice Address - Street 2:
Practice Address - City:VIBURNUM
Practice Address - State:MO
Practice Address - Zip Code:65566
Practice Address - Country:US
Practice Address - Phone:573-244-3785
Practice Address - Fax:573-244-3700
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003004928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty