Provider Demographics
NPI:1619003399
Name:COLONIAL HEIGHTS PHARMACY, INC.
Entity Type:Organization
Organization Name:COLONIAL HEIGHTS PHARMACY, INC.
Other - Org Name:COLONIAL HEIGHTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST / PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:423-239-9191
Mailing Address - Street 1:4221 FT. HENRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663
Mailing Address - Country:US
Mailing Address - Phone:423-239-9191
Mailing Address - Fax:423-239-0382
Practice Address - Street 1:4221 FT. HENRY DRIVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663
Practice Address - Country:US
Practice Address - Phone:423-239-9191
Practice Address - Fax:423-239-0382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN333600000X
TN5003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452937Medicaid
TNC08403557Medicare ID - Type Unspecified
TN0697160001Medicare NSC