Provider Demographics
NPI:1750164265
Name:SMITH, COLIN MICHAEL
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-3926
Mailing Address - Country:US
Mailing Address - Phone:716-683-7971
Mailing Address - Fax:
Practice Address - Street 1:4815 BROADWAY
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-3926
Practice Address - Country:US
Practice Address - Phone:716-683-7971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist