Provider Demographics
NPI:1871674366
Name:COLOSSEUM, INC.
Entity Type:Organization
Organization Name:COLOSSEUM, INC.
Other - Org Name:ER DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:734-955-9110
Mailing Address - Street 1:27260 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4845
Mailing Address - Country:US
Mailing Address - Phone:734-955-9110
Mailing Address - Fax:734-955-9101
Practice Address - Street 1:27260 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4845
Practice Address - Country:US
Practice Address - Phone:734-955-9110
Practice Address - Fax:734-955-9101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007587332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4431348Medicaid
MI540H221480OtherBLUE CROSS BLUE SHEILD
MI4431348Medicaid