Provider Demographics
NPI:1114523453
Name:COLEMAN, CORY JOSEPH (RPH)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:JOSEPH
Last Name:COLEMAN
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 1:6887 REVERE DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9522
Mailing Address - Country:US
Mailing Address - Phone:716-982-6924
Mailing Address - Fax:
Practice Address - Street 1:6939 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9406
Practice Address - Country:US
Practice Address - Phone:716-947-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist