Provider Demographics
NPI:1881575405
Name:OLSEN, TANNER WAYNE (PHARMD)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:WAYNE
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SE CHURCHILL WAY
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-6414
Mailing Address - Country:US
Mailing Address - Phone:915-229-9212
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:580-250-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist