Provider Demographics
NPI:1609208586
Name:VIA, COLETTE LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:LYNN
Last Name:VIA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK AVE
Mailing Address - Street 2:SUITE FRONT E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:800-874-5881
Mailing Address - Fax:
Practice Address - Street 1:100 PARK AVE
Practice Address - Street 2:SUITE FRONT E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:800-874-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12169183500000X
NC22405183500000X
NY062865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist