Provider Demographics
NPI:1275838492
Name:COLONIAL LTC PHARMACY, INC
Entity Type:Organization
Organization Name:COLONIAL LTC PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRAYTON
Authorized Official - Last Name:LANGDON
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-868-4073
Mailing Address - Street 1:100 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-1027
Mailing Address - Country:US
Mailing Address - Phone:315-868-4073
Mailing Address - Fax:315-736-7396
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-1027
Practice Address - Country:US
Practice Address - Phone:315-868-4073
Practice Address - Fax:315-736-7396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0305133336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy