Provider Demographics
NPI:1083893440
Name:RADOCAJ, COLEEN MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:COLEEN
Middle Name:MARIE
Last Name:RADOCAJ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15168 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1634
Practice Address - Country:US
Practice Address - Phone:631-957-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00276499Medicaid