Provider Demographics
NPI:1629187257
Name:KOLASA, TINA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:KOLASA
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 1:1019 RIVER ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019 RIVER ST
Practice Address - Street 2:SUITE #1
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9181
Practice Address - Country:US
Practice Address - Phone:608-424-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12237-040183500000X
PARP038010L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist