Provider Demographics
NPI:1912220765
Name:COLOSA, JOSEPH THOMAS (BS PHARMACY)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:THOMAS
Last Name:COLOSA
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 MELROSE PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-6268
Mailing Address - Country:US
Mailing Address - Phone:632-286-1382
Mailing Address - Fax:
Practice Address - Street 1:629 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754
Practice Address - Country:US
Practice Address - Phone:631-265-6404
Practice Address - Fax:631-265-6094
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0106.3969Medicaid