Provider Demographics
NPI:1538145222
Name:COLONIAL DRUGS OF KISSIMMEE, LLC
Entity Type:Organization
Organization Name:COLONIAL DRUGS OF KISSIMMEE, LLC
Other - Org Name:COLONIAL DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-344-5588
Mailing Address - Street 1:6912 ALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792
Mailing Address - Country:US
Mailing Address - Phone:407-344-5588
Mailing Address - Fax:407-932-3168
Practice Address - Street 1:6912 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-7003
Practice Address - Country:US
Practice Address - Phone:407-344-5588
Practice Address - Fax:407-932-3168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24126333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026259500Medicaid