Provider Demographics
NPI:1255869152
Name:COLE, ALLISEN MAE I (PHARM D)
Entity Type:Individual
Prefix:
First Name:ALLISEN
Middle Name:MAE
Last Name:COLE
Suffix:I
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:CO
Mailing Address - Zip Code:80615-0104
Mailing Address - Country:US
Mailing Address - Phone:970-454-2110
Mailing Address - Fax:970-454-1943
Practice Address - Street 1:180 S ELM AVE
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:CO
Practice Address - Zip Code:80615-8273
Practice Address - Country:US
Practice Address - Phone:970-454-2210
Practice Address - Fax:970-454-2210
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1831119452Medicaid
CO08222833Medicaid