Provider Demographics
NPI:1639586852
Name:COLBURN, JOLENE
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:COLBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3209
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:NM
Mailing Address - Zip Code:87021-3209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 ROBERT RD
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:97021
Practice Address - Country:US
Practice Address - Phone:505-285-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist