Provider Demographics
NPI:1619173556
Name:COLOMA PHARMACY INC
Entity Type:Organization
Organization Name:COLOMA PHARMACY INC
Other - Org Name:COLOMA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHABEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-468-6207
Mailing Address - Street 1:6577 PAW PAW AVE
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-8805
Mailing Address - Country:US
Mailing Address - Phone:269-468-6207
Mailing Address - Fax:269-468-6707
Practice Address - Street 1:6577 PAW PAW AVE
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-8805
Practice Address - Country:US
Practice Address - Phone:269-468-6207
Practice Address - Fax:269-468-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
MI5301008639333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619173556Medicaid
MI87-5219857Medicaid
MI50-2369812Medicaid
MI87-5219857Medicaid