Provider Demographics
NPI:1306366927
Name:COLLEY, LORI R
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:R
Last Name:COLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2174 ADDISON WAY
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-1931
Mailing Address - Country:US
Mailing Address - Phone:334-730-3585
Mailing Address - Fax:
Practice Address - Street 1:1903 COBBS FORD RD
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7230
Practice Address - Country:US
Practice Address - Phone:334-365-7774
Practice Address - Fax:334-365-4509
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2017-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist