Provider Demographics
NPI:1861172140
Name:KOTHMANN, OLIVIA NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:KOTHMANN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:NICOLE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:529 RANDLETT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73062-5501
Mailing Address - Country:US
Mailing Address - Phone:913-948-4540
Mailing Address - Fax:
Practice Address - Street 1:3401 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6332
Practice Address - Country:US
Practice Address - Phone:580-280-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist