Provider Demographics
NPI:1669117958
Name:COLLETTI, PAUL DAVID (RPH)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:COLLETTI
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 1:3730 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2020
Mailing Address - Country:US
Mailing Address - Phone:817-395-3610
Mailing Address - Fax:
Practice Address - Street 1:933 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-8807
Practice Address - Country:US
Practice Address - Phone:817-395-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist