Provider Demographics
NPI:1447987433
Name:IVANOVA, OLGA PAVLOVNA (PHARMD)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:PAVLOVNA
Last Name:IVANOVA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4214
Mailing Address - Country:US
Mailing Address - Phone:347-592-3795
Mailing Address - Fax:
Practice Address - Street 1:13960 LANDSTAR BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5524
Practice Address - Country:US
Practice Address - Phone:407-438-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS64450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS64450OtherFLORIDA STATE PHARMACIST LICENSE