Provider Demographics
NPI:1851460794
Name:COLASANTO, ELLIOTT RALPH (RPH)
Entity Type:Individual
Prefix:MR
First Name:ELLIOTT
Middle Name:RALPH
Last Name:COLASANTO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 BRIDLEPATH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4044
Mailing Address - Country:US
Mailing Address - Phone:860-620-0557
Mailing Address - Fax:
Practice Address - Street 1:340 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2529
Practice Address - Country:US
Practice Address - Phone:860-628-3972
Practice Address - Fax:860-621-7862
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0386220001Medicare ID - Type Unspecified