Provider Demographics
NPI:1619982212
Name:COLLEY DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:COLLEY DISCOUNT PHARMACY INC
Other - Org Name:COLLEY DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-622-2757
Mailing Address - Street 1:1415 COLLEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1705
Mailing Address - Country:US
Mailing Address - Phone:757-622-2757
Mailing Address - Fax:757-640-0367
Practice Address - Street 1:1415 COLLEY AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1705
Practice Address - Country:US
Practice Address - Phone:757-622-2757
Practice Address - Fax:757-640-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010022093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008510059Medicaid
2102952OtherPK