1134237894 NPI number — COLONIAL PHARMACY OF WHITESBORO INC

Table of content: (NPI 1134237894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134237894 NPI number — COLONIAL PHARMACY OF WHITESBORO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL PHARMACY OF WHITESBORO INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134237894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITESBORO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13492-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-736-2122
Provider Business Mailing Address Fax Number:
315-736-7376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITESBORO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13492-1027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-736-2122
Provider Business Practice Location Address Fax Number:
315-736-7376
Provider Enumeration Date:
08/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LANGDON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
BRAYTON
Authorized Official Title or Position:
PRESIDENT SUPERVISING PHARMACIST
Authorized Official Telephone Number:
315-736-2122

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  025256 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 025256 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02228999 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3324681 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".