Provider Demographics
NPI:1063012870
Name:COLLOM, PATRICK DONALD (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DONALD
Last Name:COLLOM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 ENCORE BLVD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-6016
Mailing Address - Country:US
Mailing Address - Phone:989-772-6302
Mailing Address - Fax:989-773-9362
Practice Address - Street 1:4730 ENCORE BLVD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-6016
Practice Address - Country:US
Practice Address - Phone:989-772-6302
Practice Address - Fax:989-773-9362
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist