Provider Demographics
NPI:1306822077
Name:COLONIAL VILLAGE
Entity Type:Organization
Organization Name:COLONIAL VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:REAL
Authorized Official - Last Name:FOURNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-746-5085
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:CONTOOCOOK
Mailing Address - State:NH
Mailing Address - Zip Code:03229-0338
Mailing Address - Country:US
Mailing Address - Phone:603-746-5085
Mailing Address - Fax:603-746-4117
Practice Address - Street 1:54 PARK AVE PLAZA
Practice Address - Street 2:
Practice Address - City:CONTOOCOOK
Practice Address - State:NH
Practice Address - Zip Code:03229-0338
Practice Address - Country:US
Practice Address - Phone:630-746-4600
Practice Address - Fax:603-746-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0101183500000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3002552OtherNABP
NH80872938Medicaid
NH0166920001Medicare NSC