Provider Demographics
NPI:1578749941
Name:COLONIAL PHARMACY INC
Entity Type:Organization
Organization Name:COLONIAL PHARMACY INC
Other - Org Name:COLONIAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BURSTYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-447-3591
Mailing Address - Street 1:1326 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7512
Mailing Address - Country:US
Mailing Address - Phone:626-447-3591
Mailing Address - Fax:626-447-4679
Practice Address - Street 1:1326 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7512
Practice Address - Country:US
Practice Address - Phone:626-447-3591
Practice Address - Fax:626-447-4679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA441563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA441560Medicaid
5636456OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA441560Medicaid