Provider Demographics
NPI:1114271269
Name:COLYER ZAGELOW, LAURA (RPH)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:COLYER ZAGELOW
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 1:2761 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2246
Mailing Address - Country:US
Mailing Address - Phone:608-365-4418
Mailing Address - Fax:608-365-2023
Practice Address - Street 1:2761 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2246
Practice Address - Country:US
Practice Address - Phone:608-365-4418
Practice Address - Fax:608-365-2023
Is Sole Proprietor?:No
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17617183500000X
WI15179-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist