Provider Demographics
NPI:1841408085
Name:COLBURN, WILLARD RUDIN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:RUDIN
Last Name:COLBURN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2050
Mailing Address - Country:US
Mailing Address - Phone:860-429-1654
Mailing Address - Fax:
Practice Address - Street 1:188 UNION ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-2429
Practice Address - Country:US
Practice Address - Phone:860-896-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist