Provider Demographics
NPI:1073837308
Name:COLLEA, DONALD
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:COLLEA
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 1:12026 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:14590-1022
Mailing Address - Country:US
Mailing Address - Phone:315-594-1212
Mailing Address - Fax:315-594-2971
Practice Address - Street 1:12026 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:NY
Practice Address - Zip Code:14590-1022
Practice Address - Country:US
Practice Address - Phone:315-594-1212
Practice Address - Fax:315-594-2971
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3301998Medicaid