Provider Demographics
NPI:1437184926
Name:COLONIAL HEALTH PHARMACY
Entity Type:Organization
Organization Name:COLONIAL HEALTH PHARMACY
Other - Org Name:COLONIAL HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANG
Authorized Official - Prefix:
Authorized Official - First Name:LATCHMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGHUNADAN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:973-824-5010
Mailing Address - Street 1:125 AVON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-2531
Mailing Address - Country:US
Mailing Address - Phone:973-824-5010
Mailing Address - Fax:973-799-0066
Practice Address - Street 1:125 AVON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-2531
Practice Address - Country:US
Practice Address - Phone:973-824-5010
Practice Address - Fax:973-799-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS005711003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2054145OtherPK
NJ7946007Medicaid