Provider Demographics
NPI:1003575598
Name:KOLAGA, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KOLAGA
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:W2183 STATE ROAD 33
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-2601
Mailing Address - Country:US
Mailing Address - Phone:920-557-1863
Mailing Address - Fax:
Practice Address - Street 1:351 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7932
Practice Address - Country:US
Practice Address - Phone:920-231-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-11
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21156-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist