Provider Demographics
NPI:1013041557
Name:COLONIAL PHARMACY INC
Entity Type:Organization
Organization Name:COLONIAL PHARMACY INC
Other - Org Name:COLONIAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-967-4442
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04046-0646
Mailing Address - Country:US
Mailing Address - Phone:207-967-4442
Mailing Address - Fax:207-967-3378
Practice Address - Street 1:40 DOCK SQ
Practice Address - Street 2:
Practice Address - City:KENNEBUNKPORT
Practice Address - State:ME
Practice Address - Zip Code:04046-6011
Practice Address - Country:US
Practice Address - Phone:207-967-4442
Practice Address - Fax:207-967-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MEPH500000113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035682OtherPK
2035682OtherPK
2000139OtherOTHER ID NUMBER