Provider Demographics
NPI:1598383804
Name:COLLAZO, MADELLINE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MADELLINE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3786 ROSEMARY TER
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4520
Mailing Address - Country:US
Mailing Address - Phone:228-497-4483
Mailing Address - Fax:
Practice Address - Street 1:3786 ROSEMARY TER
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4520
Practice Address - Country:US
Practice Address - Phone:228-497-4483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No183500000XPharmacy Service ProvidersPharmacist